Pre-app Cover Details
Created On
Jan, 01 1970 00:00am
ID #
Pre-app Cover Details
Attached
Required Document Checklist :
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Merchant
(Business) DBA Name :
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Business Legal Name :
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Contact Name :
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Contact Phone Number :
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Physical
Address :
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City :
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State :
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Country :
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Zip :
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Phone Number :
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Fax Number :
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Email Address :
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Website :
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Billing Address
Address :
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City :
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State :
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Country :
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Zip :
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Business Type
State incorporated in :
Public
Type of Legal Entity :
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Business Type :
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Business Start Date :
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EIN/Federal Tax ID Type :
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EIN/Federal Tax ID# :
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Types of Goods Sold :
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Ownership Information
Owner 1
Officer/Owners Name:
David Torge
Title :
Owner
Social Security:
791-07-0289
Home Address:
2021 Anna Lee St
City :
Opelousas
State:
LA
Country:
Zip:
70570
Drivers License:
011904752
Issue Date:
Jun, 04 2021
Expiration Date:
Oct, 21 2027
State:
LA
DOB:
Oct, 21 1993
Home Phone Number:
337-290-5024
% of Business Owned :
50
Length of Ownership :
2 months
Owner 2
Officer/Owners Name:
Victoria Torge
Title :
Owner
Social Security:
436-83-3253
Home Address:
2021 Anna Lee St
City :
Opelousas
State:
LA
Country:
Zip:
70570
Drivers License:
009395297
Issue Date:
Nov, 15 2024
Expiration Date:
Nov, 15 2030
State:
LA
DOB:
Nov, 15 1991
Home Phone Number:
337-308-2807
% of Business Owned :
50
Length of Ownership :
2 MONTHS
Banking Information
Billing Type :
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Name of Bank :
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ABA Routing :
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Account :
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Estimated Sales Volume
Estimated Annual Sales Visa/MC/Discover/ AMEX Sales :
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Estimated Monthly Visa/MC/Discover/ AMEX Sales :
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Average Ticket :
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High Ticket :
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Business Profile
Card Swiped :
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Card Keyed In :
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0%
Card Present :
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Card Not Present :
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0%
Moto :
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Internet :
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Notes :
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Terminal Answer
Batch Out Time :
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Terminal Type :
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Communication Method :
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Do You Dial 9 For Outside Line? :
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Reprogram Terminal :
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Equipment Purchase :
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Equipment Rental Program :
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Next Day Funding :
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Tip Edit :
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EBT :
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FNS Number :
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Tax Calculation :
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If So Tax Rate :
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Refund Policy :
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Print Refund Policy On Footer :
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Software Or POS Integration Answer
POS Software Integration :
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Software Name & Version :
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MP/AP Name :
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RP Name :
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Pricing Provided :
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Receipt Header Message :
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Receipt Footer Message :
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