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

* 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

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

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 and ACH

* 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 (if not already provided)

- Voided Check

- Copy of Application Signer's Driver's License

- Copy of 501c3 verification

- 2 years of Financial Statements

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

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 Pre-Application - for Merchant Accounts

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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