apply now

Please fill out this application as completely as possible. Questions? Call us at 877-277-7687

Legal Business Name

DBAs (if any)

Website(s)

EIN

Time In Business

Contact Name

Contact Telephone

Contact Email

Legal Address

Apt/Suite/Etc.

City

State

Zip Code

Different Mailing Address?

Mailing Address

Apt/Suite/Etc.

City

State

Zip Code

Owner 1 Name

Ownership %

Title

Phone Number

Date of Birth

SSN

Address

Apt/Suite/Etc,

City

State

Zip Code

Filed For Bankruptcy?

Ever Been Placed on The Match List or any Chargeback Monitoring Program?

Additional Owner over 25%?

Owner 2 Name

Ownership %

Title

Phone Number

Date of Birth

SSN

Address

Apt/Suite/Etc,

City

State

Zip Code

Filed For Bankruptcy?

Ever Been Placed on The Match List or any Chargeback Monitoring Program?

Additional Owner over 25%?

Owner 3 Name

Ownership %

Title

Phone Number

Date of Birth

SSN

Address

Apt/Suite/Etc,

City

State

Zip Code

Filed For Bankruptcy?

Ever Been Placed on The Match List or any Chargeback Monitoring Program?

Currently Processing?

Average Purchase Amount

High Purchase Amount

Anticipated Monthly Volume

Please Describe Your Product/Service

Customer Service Handled

Customer Service Telephone

Customer Service Email

Fulfillment Handled

Card is Charged

Is There Any Recurring Billing?

Owner 1 Photo ID

Owner 2 Photo ID

Owner 3 Photo ID

Articles of Incorporation / Articles of Organization / Etc.

SS4 / EIN Verification

Voided Check / Bank Letter (For Deposits)

Bylaws / Capitalization Table / Other Document Showing Breakdown of Ownership

Customer Service Agreement

Fulfillment Agreement

Bank Statements

Processing Statements

apply now

CONTACT Us

Join OUR NEWSLETTER