Application Please enable JavaScript in your browser to complete this form.Business Name (DBA = "Doing Business As" Name) *Business Physical Address *Business Mailing Address (if different than physical)Business Phone *Business Email *# of Years in Business *Type of Business *Sole ProprietorLLCIncorporatedPartnershipNon-Profit 501c/Tax ExemptOtherCorporate/Legal Name (if incorporated)Corporate Address (if different than physical business)Corporate PhoneBusiness Category *RetailRestaurantConvenience/Liquor StoreB2BeCommerceDispensaryLodgingSupermarketGas Station/Car WashCharity/Non-ProfitOtherProducts/Services Sold *Currently Accept Visa and MasterCard? *YesNoCurrent Credit Card Processor Company NameWhat type of equipment would you like? *POS Integration (i.e. Sam4s, NRS, etc.)Stand Alone EMV TerminalMobile EMV Card ReaderGateway/Virtual TerminalWorkstationeCommerce WebsiteOtherAverage Monthly Credit Card Sales Volume $ *Average Transaction $ Amount *Tax ID / EIN # **** IMPORTANT ***Please list all owners with 25% or more ownership belowOwner #1 Name *FirstLastOwner #1 Title *OwnerCEOPresidentVPPartnerLLC MemberCFOCOOOwner #1 Ownership Percentage (Must be 25% or more) *Owner #1 Residence Address *Owner #1 Email *Owner #1 Mobile Phone *Owner #1 Date of Birth *Additional Owner #2 NameFirstLastOwner #2 TitleOwnerCEOPresidentVPPartnerLLC MemberCFOCOOOwner #2 Ownership Percentage (Must be 25% or more)Owner #2 Residence AddressOwner #2 EmailOwner #2 Date of BirthAdditional Owner #3 NameFirstLastOwner #3 TitleOwnerCEOPresidentVPPartnerLLC MemberCFOCOOOwner #3 Ownership Percentage (Must be 25% or more)Owner #3 Residence AddressOwner #3 EmailOwner #3 Date of BirthComment or MessageSubmit