Merchant

1. MERCHANT INFORMATION

NAME OF ACCOUNT (DOING BUSINESS AS)

DBA ADDRESS (IF DIFFERENT FROM LEGAL)

ADDRESS

City

State

Zip Code

AUTHORIZED CONTACT

DATE OF BIRTH

MERCHANT E-MAIL ADDRESS (AGENT E-MAIL ADDRESS CANNOT BE ACCEPTED)

EXACT LEGAL NAME

LEGAL ADDRESS

ADDRESS

City

State

Zip Code

TELEPHONE #

FAX #

FEDERAL TAX I.D. NUMBER (9 DIGITS)

WEBSITE ADDRESS

3. BANKING INFORMATION

NAME OF MERCHANT'S BANK

BANK LOCAL TELEPHONE #

CONTACT

ROUTING/ABA #

DBA CHECKING ACCOUNT

4. CERTIFICATION OF BENEFICIAL OWNER(S)

I: BENEFICIAL OWNERSHIP INFORMATION: Provide the following information for each individual, if any, who directly or indirectly, through any contract, arrangement, understanding, relationship or otherwise, owns 25% or more of the equity interest of the legal entity listed on this form. If no individual meets this definition, please enter the business's owners or officers and enter 0% as "% of ownership".

#1 Last Name

First Name

ADDRESS (NO P.O. BOX)

CITY

EMAIL ADDRESS

MOBILE #

ID TYPE

PASSPORT # (NON-US CITIZENS)

M.I.

DOB

% OF OWNERSHIP

STATE

ZIP

SS (US PERSONS)

ID #

EXP. DATE

ISSUING STATE/COUNTRY

II: MANAGING RESPONSIBILITY (REQUIRED): Provide information below for one individual with significant responsibility for managing the legal entity previously listed on this form, such as, an executive officer or senior manager (e.g. Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, Treasurer); or Any other individual who regularly performs similar functions. If appropriate, an individual listed in C: BENEFICIAL OWNERSHIP INFORMATION (above) may be listed in this section. INDIVIDUAL WITH SIGNIFICANT CONTROL:

Last Name

First Name

ADDRESS (NO P.O. BOX)

CITY

ID TYPE

ID #

PASSPORT # (NON-US CITIZENS)

EMAIL ADDRESS

M.I.

DOB

% OF OWNERSHIP

STATE

ZIP

SS (US PERSONS)

EXP. DATE

ISSUING STATE/COUNTRY

MOBILE #

TITLE

5. MERCHANT ACCOUNT RATES

Name:

Address:

City:

State:

Zip Code:

Telephone Number:

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Merchant Application

1. MERCHANT INFORMATION

2. MERCHANT PROFILE

3. BANKING INFORMATION

4. CERTIFICATION OF BENEFICIAL OWNER(S)

5. MERCHANT ACCOUNT RATES

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