Application

Business Name *

Business Location Address *

Mailing Address (if different than business)

Business Phone *

Business Email *

Years in Business *

Type of Business *Sole ProprietorLLCIncorporatedPartnershipNon-Profit 501c/Tax ExemptOther

Corporate/Legal Name (if incorporated)

Corporate Address (if different than business)

Corporate Phone

Business Category *RetailRestaurantB2BInternet/eCommerceDispensaryLodgingSupermarketGas Station/Car WashCharity/Non-ProfitOther

Products/Services Sold *

Currently Accept Visa and MasterCard? *

• Yes
• No

Current Credit Card Processor Company Name

What type of equipment would you like? *Stand Alone EMV TerminalMobile EMV Card ReaderPOS IntegrationGateway/Virtual TerminaleCommerceOther

Average Monthly Credit Card Sales Volume $ *

Average Transaction $ Amount *

Tax ID / EIN # *

Primary Contact Name *

First

Last

Primary Contact Title *OwnerCEOPresidentVPPartnerLLC MemberCFOCOO

Primary Contact % of Ownership (Must be 51% or more) *

Residence Address *

Primary Contact Date of Birth *

Comment or Message

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