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Merchant Application & Agreement
Merchant Application & Agreement
Please enable JavaScript in your browser to complete this form.
1. BUSINESS INFORMATION
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Step
1
of 7
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Legal Name:
*
Corporate Address:
*
City:
*
State:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
*
Contact Business #:
*
Federal Tax Id#:
*
Merchant Name (Dba Or Trade Name):
*
DBA Address Location:
*
Same as Legal Address:
Yes
Corporate Address:
*
City:
*
State:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
*
Contact Business #:
*
Email Address:
*
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Years In Business:
*
# Of Locations:
*
Please Choose Mailing Address:
*
DBA
LEGAL
WEBSITE:
NOTE: Failure to provide accurate information may result in a withholding of merchant funding per: IRS regulations
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All Owners with up to 25% or more ownership or owners with significant responsibility managing the legal entity must be added.
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Are there additional owners/ partners/officers?
Name:
*
First
Last
Home Address:
*
Address Line 1
State:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
City
*
Zip:
*
Country
*
United States of America
Social security number
*
Date of Birth:
*
Mobile Phone Number
*
Are there additional owners/ partners/officers?
Additional information for ownership:
*
Yes
No
Name:
*
First
Last
Address:
*
Address Line 1
State:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
City
*
Zip:
*
Country
*
United States of America
Social security number:
*
Mobile Phone Number
*
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Prior Bankruptcies:
*
Yes
No
Prior Bankruptcies:
*
Business
Personal
Date Discharged:
*
*Each individual who owns, directly or indirectly through any contract, arrangment, understanding relationship or otherwise, 25% or more of the equity interests of the Client, or who is the Client’s sole proprietor, must be added. ** A Guarantor means a “beneficial owner” who is identified as the authorized signer, with significant responsibility and control (e.g. Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, Treasurer). ***An addendum will be provided for any owner not stated on the application with 25% or more ownership in the aforementioned company(or legal entity)
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DOES THIS LOCATION CURRENTLY TAKE VISA/MASTERCARD/DISCOVER® NETWORK?
*
Yes
No
Average Ticket $
*
Maximum Ticket $
*
Monthly Volume $
*
Must equal to 100%
Retail Chip/Swipe %
*
Card Present Keyed %
*
Internet %
*
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OWNERSHIP: MUST PROVIDE DOCUMENTATION
*
INDIVIDUAL / SOLE PROPRIETOR
LLC
PA/PC
PUBLICLY TRADED
PARTNERSHIP
CORPORATION
GOVERNMENT
NON-PROFIT
OTHER
BUSINESS TYPE:
*
RETAIL
RESTAURANT
SERVICE
INTERNET
LODGING
OTHER
Goods and services:
*
Bank Name:
*
Routing Number #:
*
Account Number #:
*
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If you process 20% or more of your credit card volume without chip and or card present, please complete the section below:
1. Please submit your product catalog, brochures, promotional materials, a current price list, and a copy of your service agreement with card holder if applicable. If on the internet, please include screen-prints of your website address if your site is not yet active.
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2. If internet, please check your type of business.
5. CARD NOT PRESENT INFORMATION
Domain Registration
Web Page Design
Auction
Internet Service Gateway
Selling Digital Service
Advertisement
Selling Hard Goods
Other
Other
If you’re an e-commerce business or if you’re selling online, list the encryption methods, vendors and controls used to secure transaction information
3. How will the product be advertised or promoted?:
4. Billing Methods (Check All that Apply):
Monthly %
Yearly %
Quarterly %
One Time %
Hourly %
Monthly %
Yearly %
Quarterly
One Time
Hourly
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By executing this Merchant Application on behalf of the merchant described above (the “Merchant”), the undersigned individual(s): (i) represent(s) and warrant(s) that all information contained in this Merchant Application is true, correct and complete as of the date of this Merchant Application, and that such individual(s) have the requisite corporate power and authority to complete and submit this Merchant Application and make and provide the acknowledgements, authorizations and agreements set forth below, both on behalf of the Merchant and individually; (ii) acknowledge(s) that the information contained in this Merchant Application is provided for the purpose of obtaining, or maintaining a merchant account with Bank on behalf of the Merchant; (iii) authorize Bank to investigate the credit of the Merchant and each person listed on this Merchant Application; (iv) agree, on behalf of the Merchant and in the event this Merchant Application is accepted and executed by Bank, to the Fee Schedule set forth above and to the Terms and Conditions included with and incorpo- rated into this Merchant Agreement. Merchant understands that this Agreement shall not take effect until Merchant has been approved by Bank and a merchant number is issued.
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Merchant DBA Name:
*
Owner Name:
*
Date:
*
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Thank you for completing our preliminary application, we will contact you next 24 to 48 hours to verify your information from a Monero Payments solutions specialist.
Please select below what time you prefer to reach you (EST)?
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Best time to reach
*
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FINISH/SUBMIT