Use this form to get started if you don't have credit card processing or would like us to quote for credit card processing services.

Do you have questions about this form? Click here for a FAQ regarding Merchant Accounts and how this process is different (and better) than a 'big tent' service like Paypal or Stripe.
Applicant Information
This is the name of the individual that will be filling out the application for payment processing. This may or may not be the principal of the organization. That data will be collected later.
Applicant Name*
First Name Last Name
Applicant Email Address*
Applicant Telephone*
Additional Information
Please provide additional information about your business here.

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Business Information
Legal Name of Business*
DBA
EIN / Tax ID
We will call you for this number which is used to perform a background and credit check. While our site and form is secure, we prefer not to keep a local copy of this data which will be directly entered into the application for underwriting with the bank.
State Filed*
Business Type*
Business Start Date*
MM slash DD slash YYYY
Street Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address (if different from Street Address)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business Telephone*
Business Email Address*
Customer Service Telephone
Customer Service Email Address
Website*

If website is not ready, please provide "dummy" login for test website.
Alternate Website
Website Notes
Please include any comments about the site and the development process. If a Username and Passsword are required to view the site, please include those here.
Authorized Contact*
First Name Last Name
Is there another individual who we can speak with about the account, or who can contact us to inquire about application status or processing in the future?
Type of Terminal / Equipment

i.e., VX 520 Terminal, Authorize.net Gateway, Mobile Card-Reader
Number of Employees*
Office Location*
Approximate Square Footage*
Own or Rent?*

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Principal Information
Full Name*
First Name Middle Last Name
Title*

ex: Owner, CEO, President, etc.
Ownership Percentage*
Please include all owners with 25% or more equity. Click the "+" icon to add additional rows.
Name Percentage
Social Security Number
We will call you for this number which is used to perform a background and credit check. You will need to have this information available for all business owners. While our site (and this form) is secure, we prefer not to keep a local copy of this data which will be directly entered into the application for underwriting with the bank.
Date of Birth*
MM slash DD slash YYYY
Driver License Number*
License State*
License Expiration Date*
MM slash DD slash YYYY
Home Telephone*
Personal Email Address*
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Applicant Information

Business Information

Name	Percentage