IBO Info

Tell us a little about the IBO who referred you

IBO ID*

IBO First Name*

IBO Last Name*

IBO Email*

IBO Phone*

IBO Relationship

Merchant Contact Information

Tell us who we should contact at the Business to follow-up with about your application

First Name*

Last Name*

Email Address*

Phone*

Alternate Phone

Time Zone*

Best Time to Contact*

Merchant Business Information

Tell us a little bit about your business and its Payments needs.

Merchant DBA Name*

Business Website

Merchant DBA Address*

Address 2

Merchant DBA City*

Merchant DBA State*

Merchant DBA Zip*

Merchant Business Legal Information

Tell us how your company was formed

Legal Business Name*

Federal Tax Id*

Business Start Date*

Legal Entity Type*

Business Legal Address*

Address 2

Business Legal City*

Business Legal State*

Business Legal Zip*

Merchant Processing Information

Tell us a little bit about how you accept payments

Do you currently accept credit cards?*

Yes

No

How many business locations do you have?*

How do you accept payments? (Check all that apply)

Face to face, in-store

Through my company website

On the go, mobile

Manual key enter

Products/Services Sold*

Monthly Volume?* ?

$

Average Transaction Size?* ?

$

Highest Transaction?* ?

$

Applicants / Business Principal(s)

Information about the primary owners of this business. PLEASE NOTE: Information must be provided for all principals owning more than 20% of the business.

First Name*

Last Name*

Title*

Ownership %*

Home Phone*

Email*

Date of Birth*

Social Security Number*

Address 1*

Address 2

City*

State*

Zip*

Notes

Thoughts, questions, or concerns? Just let us know.

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IBO Info

Merchant Contact Information

Merchant Business Information

Merchant Business Legal Information

Merchant Processing Information

Applicants / Business Principal(s)

Notes