BUSINESS INFORMATION Type of Business * Select Business Type Select Business Type Corporation Sole Proprietorship Partnership Tax Exempt Organization Government (Does not apply) Private limited liability corporation Publicly traded limited liability corporation Publicly traded partnership Location Phone # * Please enter the location phone. Primary Email * Please enter the primary email. Confirm Primary Email * Please confirm the primary email. Corporate Name * Please enter the corporate name. Name of Business (DBA) * Please enter the name of business (DBA). Is Location Address is different from Corporate Address Corporation Types * Select Corporation Type Select Corporation Type Limited Liability Company S Corporation C Corporation Limited Liability Partnership Non-Profit Organization N/A State of Incorporation * Select Corporation State Select Corporation State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY N/A Tax ID * Please enter the Federal Tax ID Corporate Address * Reminder: Please make sure you enter your business address here and NOT your home address unless your home address is your business address. We were not able to validate the address that you entered. You can continue with the application. City * Please enter the corporate city. State * Select State Select State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY N/A Zip * Please enter the corporate zip code. Corporate Phone # * Please enter the corporate phone #. Location Address * Reminder: Please make sure you enter your business address here and NOT your home address unless your home address is your business address. We were not able to validate the address that you entered. You can continue with the application. City * Please enter the location city. State * Select State Select State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY N/A Zip * Please enter the location Zip code. Business Description * Please enter the business details. Time in Present Business * Please enter the number of years in business. Years Please enter the number of months in business. Months Average Monthly Volume * -Select Average Monthly Volume- -Select Average Monthly Volume- $250 to $499 $500 to $999 $1,000 to $2,499 $2,500 to $4,999 $5,000 to $7,499 $7,500 to $9,999 $10,000 to $24,999 $25,000 to $49,999 $50,000 to $100,000 $100,000 or More Average Sale * -Select Average Sale- -Select Average Sale- $1 to $9 $10 to $24 $25 to $49 $50 to $99 $100 to $249 $250 to $499 $500 to $999 $1,000 to $2,499 $2,500 or More Previous Processor AMV (MC/Visa Only) Please enter Previous Processor AMV (MC/Visa Only). OWNERSHIP INFORMATION # 1 Last Name * Please enter the owner last name. First Name * Please enter the owner first name. Middle Initial Please enter the owner middle initial. Email Address * Please enter the owner email. Address * Reminder: Please make sure you enter your home address here and NOT your business address unless your home address is your business address. We were not able to validate the address that you entered. You can continue with the application. City * Please enter the owner home city. State * Select State Select State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY N/A Zip * Please enter the owner home zip code. Cell Phone # * Please enter the owner cell phone #. Date of Birth * Please enter the owner date of birth. Driver’s License # * Please enter the owner driving license #. Driver’s License State * Select State Select State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY N/A WHERE DO WANT YOUR MONEY DEPOSITED? Bank Name * Please enter the bank name. Bank Routing # * Please enter the trans routing #. Yes the trans routing number is valid. Confirm Bank Routing # * Please confirm your bank routing #. Deposit Account # * Please enter your deposit account #. Confirm Deposit Account # * Please confirm your deposit account #. I have read and agree to the terms, conditions and fees. MERCHANT ACCEPTANCE # 1 Signature Owner/Authorized Officer * Type It Title * Please enter the title. Date Merchant Sign Date and Time