BUSINESS INFORMATION

    Legal Name (as it appears on IRS documents)*

    Legal Address Line 1*

    Address Line 2

    City*

    State*

    ZIP Code*

    Phone Number*

    Fax Number

    Length of Time Owned*

    Years* Months*

    Federal Tax ID*

    Business Type* (Corporation, LLC, Nonprofit)

    Billing Contact Name*

    Billing Contact Phone*

    Billing Contact Email*

    Average Sale (usual transaction amount)*

    Estimated Annual Credit Card Sales*

    OWNER INFORMATION

    Copy of a current driver's license (please upload a scanned photo or image under 16MB)*

    Copy of a voided check where funds deposit (please upload a scanned photo or image under 16MB)*

    Home Phone Number*

    Email*

    Social Security Number*

    BANKING INFORMATION

    ABA or Routing Number (9 digits)*

    DDA or Account Number (funds deposit)*

    *All sensitive information is secured and destroyed in compliance with the Payment Card Industry Data Security Standard and all other regulations that may apply.