Provide our team with...
Personal Information Form
Billing Card


This information is used solely for the purpose of acquiring your Business License, and for applying for your Merchant Application. We do not store or keep this information. 

Name
Email
Bank Name
Social Security Number and (and EIN if they have one)
Business/Corporate Name as appears on Business License? This is different than the DBA, this will be the individual’s name on a sole proprietorship
Driver's License Number
Driver's License State Issued
Driver's License Expiration Date
Phone
Would You Like Us to Set Up Your Business as a Sole-Proprietor?
Date of Birth
What is the address where you will be operating? Please include City, State and ZIP
Is the business location a home address or business address?
If you are starting a home based business, do you own your home?
If you don't own your home, what is the name, address and phone number of your landlord?
Driver's License Date Issued
Bank Address
Bank Phone Number
Checking Account Number
Bank Routing Number
Are you Providing a Credit Card or a Debit Card?
Card Number
Card Billing Address (if different from the address you already provided above)
CSV Code (3 digit code on the back of your card)
Card Expiration Date
Do you have an Apple ID? If so, list ID/Password below.
If you do own your home, how long have you lived there?
Submit


The billing information provided below will be used as the primary billing card for your third party accounts. If you are providing a card for the purpose of making a payment on the business package, specify in the contact form below.
Card Type (Visa, MasterCard, etc.)
Name on Card
Billing Zip Code
Billing City / State
Billing Address
Card Number
Expiration
CVV Code
Are you providing this card for your accounts or for an installment?
Submit