Admin Client || Dee Karawadra

In order to get our Merchants, set up seamlessly and effortlessly we need as much information as you can upfront. Please fill out all applicable fields.

Select Agent*

Select Lead

Date Submitted

Merchant Application Submission Form

Merchant (Business) DBA Name*

Business Legal Name:*

Contact Name

Contact Phone Number*

Physical Address *

City *

State *

Country *

Zip *

Phone Number

Fax Number

Email Address *

Website

Billing Address

Same as physical address

Address *

City *

State *

Country *

Zip *

Business Type (For Sole Proprietor accounts, the IRS requires that the Business Legal Name and Business Tax ID match the Business Owner’s Name and Business Owner’s Tax Identification Number. Please confirm that this information matches IRS requirements and merchant tax reporting records. )

State incorporated in *

Type of Legal Entity *

Business Type *

Sub Business Type *

Business Start Date

EIN/Federal Tax ID Type

EIN/Federal Tax ID#

Types of Goods Sold

Ownership Information (Must be 51% or more)

Owner 1 Information

Officer/Owners Name *

Title

Social Security

Form of ID *

ID # *

Issue Date *

Expiration Date *

State *

DOB *

Home Phone Number

% of Business Owned

Length of Ownership

Y N

Home Address *

Home City *

Home State *

Home Country *

Home Zip *

Owner 1 Information

Officer/Owners Name *

Title

Social Security

Form of ID *

ID # *

Issue Date *

Expiration Date *

State *

DOB *

Home Phone Number

% of Business Owned

Length of Ownership

Y N

Home Address *

Home City *

Home State *

Home Country *

Home Zip *

Banking Information No starter checks or deposit slips accepted

Billing Type *

Gross Settlement

Net Settlement

Name of Bank

ABA Routing #

Account #

Estimated Sales Volume

Estimated Annual Sales Visa/MC/Discover/ AMEX Sales
Estimated Monthly Visa/MC/Discover/ AMEX Sales
Average Ticket
High Ticket

Business Profile

Card Swiped

Card Keyed In

= 100%
Card Present

Card Not Present

= 100%

MOTO

Internet

Ibuxx

Vetbuxx

SimpleBuxx

Traditional

AutoBuxx

PrimeBuxx

Cash Advance

Notes

Software Or POS Integration Questions Only

POS Software Integration

Yes

Software Name & Version:

Pricing Provided

Statement Analysis

Quote

Receipt Header Message

Receipt Footer Message

MP/AP Name

RP Name

Password

Attached Document Checklist

Voided Check

Business Verification Document

Copy of Drivers License