Merchant Processing Intake App 2023

Please submit all intake information in order for us to send a DocuSign on your behalf

WHO IS SUBMITTING?
Lead Source
WHO IS THE REFERRAL PARTNER?
WHAT PROGRAM?
WHO IS THE SALES MANAGER?
WAS IT SELF GEN?
BUSINESS DBA
Is this an existing customer?

Is this an existing customer? Yes No
BUSINESS LEGAL NAME
BUSINESS ADDRESS BUSINESS ADDRESS
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
LEGAL ADDRESS LEGAL ADDRESS
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
SEND STATEMENT HERE

SEND STATEMENT HERE Business Address Legal Address
BUSINESS PHONE BUSINESS PHONE - ### - ### ####
BUSINESS EMAIL
FEDERAL TAX ID # / EIN
TYPE OF BUSINESS
DATE BUSINESS STARTED DATE BUSINESS STARTED / MM / DD YYYY
OWNER FIRST AND LAST NAME OWNER FIRST AND LAST NAME First Last
TITLE
OWNERSHIP %
OWNER CELL PHONE OWNER CELL PHONE - ### - ### ####
HOME ADDRESS HOME ADDRESS
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
DATE OF BIRTH DATE OF BIRTH / MM / DD YYYY
If no statement is provided, please ensure these numbers are as accurate as possible. This will ensure that there are no hold ups in underwriting and to calculate accurate PMP.
AVERAGE YEARLY CREDIT CARD VOLUME
AVERAGE CREDIT CARD TICKET
HIGHEST TICKET AMOUNT
WHERE ARE THE SALES TRANSACTED? (Total of 100%)

ex: Store Front: 98%, Telephone: 2%, Internet: 0%, Mail Order: 0%
Store Front
Telephone
Internet
Mail Order
Pricing
Rounded to the nearest
Required Items:

Required Items: Voided Business Check Driver's License Federal Tax ID Social Security Number Signatures on MPA Equipment Form Previous Processor Statement
VOIDED CHECK

Attach Files
DRIVERS LICENSE

Attach Files
ADDITIONAL DOCUMENTS

Attach Files
INSTALLATION INSTRUCTIONS

INSTALLATION INSTRUCTIONS Tech Installs Ship to Rep Ship to Merchant Other Other
Type of Equipment
Equipment detail and billing terms:

Enter the type (e.g. Clover Duo), Quantities, and billing terms (e.g. 3 Year Community Support Agreement; One-time ACH to Merchant, etc)
Does the terminal need to calculate taxes?

Does the terminal need to calculate taxes? Yes No

Must answer this question if merchant needs a terminal
Does the terminal need to be mobile?

Does the terminal need to be mobile? Yes No

Must answer this question if merchant needs a terminal
Who should the DocuSign go to?
Other notes:

Merchant Processing Intake App 2023

Merchant Processing Intake App 2023

If no statement is provided, please ensure these numbers are as accurate as possible. This will ensure that there are no hold ups in underwriting and to calculate accurate PMP.

WHERE ARE THE SALES TRANSACTED? (Total of 100%)

Pricing