Legal Business Information Legal Address* Legal City* Legal State* State Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Legal Zip* Type of Business* LLC SOLE PARTNERSHIP 501c3 CORP GOVT Federal Tax Id , SSN if Sole Prop* Date Business Started* Doing Business As Information Doing Business As* Doing Business As Address Required if different than Legal Address Doing Business Address City State State Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip Doing Business Phone Merchant Profile Website Type of Product or Services Sold* Business Processing Type * RETAILECOMMERCEMOTO Card Acceptance Method: Must Equal 100% Card Swiped %* Keyed, Card Present %* MOTO, Virtual Terminal %* Ecommerce % Average Transaction* High Transaction* Monthly Volume* Do you currently accept credit cards?* Select One Yes No Prior Bankruptcy?* Select One Yes No Number of Locations* Bank Information Bank Name * Account Number * Routing Transit Number* Owner Information Title* Mobile Phone Number * Date of Birth (MM/DD/YYYY)* Social Security Number* Driver's License Number* Driver's License State* Driver's License Issue Date* Driver's License Expiration Date* Ownership Percentage* If Ownership is less than 50% additional Owner information required. Add Owner? Select One Yes No If YES is selected, we will need to have a section open up with the following fields to complete. First Name* Last Name* Phone Number* Email* Title* Ownership Percentage* Address* City* Legal State* State Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Legal Zip* Social Security Number* Date of Birth (MM/DD/YYYY)* Driver's License Number* Driver's License State* Driver's License Issue Date* Driver's License Expiration Date* Prior Bankruptcy? * Select One Yes No Additional Notes about your business Page 3 Ecommerce, MOTO Information Required Fields if processing on a Website or MOTO transactions Sales to Consumer % Sales to Businesses % Sales to Government % Sales to Consumer % Days to Deliver Goods or Services Seasonal Merchant? Y/N Describe Refund Policy Recurring Billing? If Yes, Monthly/Quarterly/Yearly Who performs fulfillment of product? Names and addresses Vendor Names and addresses Describe process of sale
