Merchant Processing Application Business Details Contact Information First Name(required) Last Name(required) Email(required) Phone Number(required) Business Legal Name(required) DBA Name (Doing Business As) Tax Filing Name(required) Tax EIN (Employer Identification Number)(required) Industry (MCC) Business Description(required) Business Start Date (YYYY-MM-DD)(required) Business Phone(required) Business Website Business Address Street Address 1(required) Street Address 2 City(required) State(required) Select one option AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY ZIP Code(required) Country Business Legal Mailing Address Choose one Same as the Business Address (please skip) Different (If different, please enter below) Street Address 1 Street Address 2 City State Select one option AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY ZIP Code Country Business Owner Information First Name(required) Last Name(required) Title % Ownership(required) Mobile Phone(required) Email(required) Street Address 1(required) Street Address 2 State(required) Select one option AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY City(required) ZIP Code(required) Country ADDITIONAL BUSINESS OWNERS (1) First Name First Name Last Name Last Name Title Title % Ownership Mobile Phone Email Street Address 1 Street Address 2 City State Select one option AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY ZIP Code Country Industry (MCC) Notes Please review and submit – we will reach out to you within 24 hours. If it is a time sensitive request, please enter the details in the above Notes field and we will contact you ASAP! Submit
