Merchant Application
Company Name (Tax Filing Name) *
DBA
Company Type *
Tax ID or EIN (9 digits) *
Start Date *
MM
/
DD
/
YYYY
Phone Number *
Street Address *
City *
State *
Zip Code *
Owner Information
First Name *
Last Name *
Email *
Title *
Ownership Percentage *
SSN (9 digits) *
Date of Birth *
MM
/
DD
/
YYYY
Driver License Number *
Phone Number *
Street Address *
City *
State *
Zip Code *
Bank Information
Bank Name *
Routing Number (9 digits) *
Account Number *
Voided Check *
Required
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