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Merchant ID

Legal Name

DBA Name

Processor

Agent

Split

Is Override

Password

Status

Received Date

Approved Date

Activation Date

Closed Date

Address

Address 2

City

ZIP

Country

State

Contact

Email(comma separated)

Phone

Phone 2

Cell

Fax

URL

DBA Same as Legal Address

Address

City

ZIP

Country

State

Mailing Address Same as DBA

Address

City

ZIP

Country

State

File here *	Notes *	Status	Date
	Pre App
	voided check
	DL
	Signed Application

Type

Install Date

Equipment ID

Status

Model

Purchase T.

PD Telephone

Sales Rep

Serial #

Tracking #

TID

Employee

Purchase Date

Send Email to Merchant Send Email to Sales rep Send Email to Employee

Bank 1 Information

Bank Name

Account Name

Rounting Number

Account Number

Billing Type

Gross Settlement

Net Settlement

Bank 2 Information

Bank Name

Account Name

Rounting Number

Account Number

Overrides who receive partial commission on all of T & G Trash LLC Accounts

Default Setup

Agent 1 Receives

on all Newly Inputted Accounts

Agent 2 Receives

on all Newly Inputted Accounts

Agent 3 Receives

on all Newly Inputted Accounts

Agent 4 Receives

on all Newly Inputted Accounts

Merchant

Month

Year

Merchant CMS

EIN/Federal Tax ID Type

MCC Code

EIN/Federal Tax ID #

Type of Legal Entity

State incorporated in

Types of Goods Sold

Primary Transaction Type

Internet

Swipe

Keyed

Average Ticket

Telephone Order

Annual Volume

Business Start Date

High Ticket

Persoanl Guarantor

Monthly Volume

Discount Method

Refund Policy

30 Days

60 Days

Other

None

Sr. No.	Date	Reminder Date	Employee	Note	Created by	Updated at	Updated by
1	Nov 07 2024 07:58 PM		Charlotte Groff	changed address per Travis and submitted SR 61687020 to Vantiv to have changed in their system.	Charlotte Groff	Nov 07 2024 08:03 PM
2	May 31 2024 04:51 PM		Charlotte Groff	Vantiv - Traditional - USAePay - business originally sold but new owner defaulted on payment so Travis took it over again.	Charlotte Groff	May 31 2024 04:59 PM

.....

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 *

Merchants

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Bank 1 Information

Bank 2 Information

Overrides who receive partial commission on all of T & G Trash LLC Accounts

Default Setup

Merchant CMS

Owner 1 Information