Bank Pre-Application - for Merchant Accounts

We will use the information you provide in this form to fill out a bank application on your behalf. The application will then be sent to you for review and electronic signature.

Business Information

* Doing Business As

* Legal Name of business as submitted on the last income tax return

* Date of Incorporation

mm/dd/yyyy

* Business Street Address

* Business City, State, Zip

* Website

* Primary Phone Number

* Primary Contact Name/Title

* Primary Contact Email

* Federal Tax ID

Patriot Act Information

To comply with the Patriot Act the authorized signer will need to provide verification including their address and identification.

* Application Signer Name

* Application Signer Title

* Application Signer Home Address

* Application Signer Email Address

* Application Signer Home Phone

* Driver's License Number

* Date of Issuance

* State of Issuance

* Expiration Date

* Social Security Number of Signer

* Percent Ownership of the Business

Any owners of more than 25% will need to complete the Patriot Act information.

Principal Owner #2

Principal Owner #2 Title

Principal Owner #2 Percent Ownership of the Business

Principal Owner #2 Address

Principal Owner #2 Phone

Principal Owner #2 DOB

Principal Owner #2 SSN

Principal Owner #2 Drivers License

Processing and Banking Information

* Have you accepted credit cards before?

Yes

* If yes, what is the name of the processor?

* Maximum anticipated volume for both credit card and ACH in any one month

* Bank Routing Number

* Checking Account Number

* Bank Name

Trade References

* Trade Reference 1 Name

Trade References are companies that provide services to your organization such as janitorial services, office suppliers etc.

Trade Reference 1 Account Number

If applicable

* Trade Reference 1 Phone

* Trade Reference 2 Name

Trade Reference 2 Account Number

If applicable

* Trade Reference 2 Phone

Document Attachments

PLEASE SEND THESE FORMS AS AN ATTACHMENT IN AN EMAIL TO [email protected]

- Current Merchant credit card statement 3 months (if not already provided)

- Voided Check

- Copy of Application Signer's Driver's License

- 2 years of Financial Statements

Alternatively you may send the documents via Dropbox using this link: Click Here to Upload to Dropbox

Account Details

E-mail

Enter your name and e-mail address for your confirmation

First Name

Last Name

Payment Information

Account

Online Fee:

Comments

For added Security please check the box below.

Total: