PAYQUIQ ONLINE :: The Faster Smarter Way to Pay

Bank Application Information Requirements

We will use the information you provide in this form to fill out a bank application on your behalf.

Business Information

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

* Length In Business

* Business Street Address

* Business City, State, Zip

* Website

* Primary Phone Number

* Primary Contact Name/Title

* Primary Contact Email

* Federal Tax ID

Patriot Act Information

* Application Signer Name

* Application Signer Title

* Application Signer Home Address

* Application Signer Email Address

* Application Signer Home Phone

* Driver's License Number

* Date of Birth

* Date of Issuance

* State of Issuance

* Expiration Date

Processing and Banking Information

Have you accepted credit cards before?

	Yes
	No

If yes, what is the name of the processor?

Maximum anticipated volume for both credit card

* Bank Routing Number

* Checking Account Number

* Bank Name

Trade References

* Trade Reference 1 Name

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]

- Last months credit card statement - Current Financial Statement - Copy of Signers Driver's License

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Online Fee:

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Total:

Bank Application Information Requirements

Account Details

Enter your name and e-mail address for your confirmation:

Payment Information

Credit Card

Checking Account

For added Security please check the box below.

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