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Business Organization Information

DBA NAME: 

DBA ADDRESS: 

DBA PHONE NUMBER: 

LEGAL NAME: 

LEGAL ADDRESS: 

CUSTOMER SERVICE EMAIL: 

CUSTOMER SERVICE PHONE: 

COMPANY WEBSITE: 

CONTACT/MANAGER NAME: 

FEDERAL TAX ID # (EIN): 

ENTITY TYPE: SOLE PROPRIETER☐  CORPORATION☐  LLC ☐  PARTNERSHIP☐   TAX EXEMPT☐ STATE CORP WAS FILED IN: DATE REGISTERED: _______DATE BUSINESS STARTED______ CURRENT OWNERSHIP TIME: 

# OF LOCATIONS: 

OWNER/PARTNER/OFFICER INFORMATION 

ALL OWNERS WITH GREATER THAN 25% MUST BE ON APPLICATION 

OWNER NAME: (AS IT APPEARS ON DRIVERS LICENSE) 

TITLE: 

OWNERSHIP %: 

HOME ADDRESS: 

HOME PHONE: 

CELL PHONE: 

EMAIL: 

SS#: 

DOB: 

DRIVERS LICENSE NUMBER: ________________________ STATE ISSUED: _________

 

ALL OWNERS WITH GREATER THAN 25% MUST BE ON APPLICATION 

OWNER NAME: (AS IT APPEARS ON DRIVERS LICENSE) 

TITLE: 

OWNERSHIP %: 

HOME ADDRESS: 

HOME PHONE: 

CELL PHONE: 

EMAIL: 

SS#: 

DOB: 

DRIVERS LICENSE NUMBER:

STATE ISSUED:

 

 

TRANSACTION INFORMATION 

EXPLANATION OF PRODUCTS / SERVICES SOLD: 

PREVIOUS PROCESSOR NAME: 

AVERAGE TICKET SIZE: 

HIGHEST TICKET SIZE: 

MONTHLY VOLUME: 

METHOD OF ACCEPTANCE:      PHONE %_____ SWIPE %______ INTERNET%_____ 

EQUIPMENT DETAILS 

EQUIPMENT TYPE:       TERMINAL☐     POS SYSTEM☐     INTERNET GATEWAY☐   

EQUIPMENT NAME AND MODEL: 

PROPERTY INFORMATION 

DO YOU OWN OR LEASE YOUR BUSINESS LOCATION:   LEASE☐     OWN☐   OFFICE BUILDING☐    WAREHOUSE☐    RESIDENCE☐    STOREFRONT☐    OTHER☐

LANDLORD NAME:                                                                                                                  

LANDLORD PHONE: 

LEASE TERM: 

LEASE START DATE:
 

BANK INFORMATION

BANK NAME: 

BANK PHONE NUMBER

NAME ON THE ACCOUNT:

CHECKING ACCOUNT #:

ROUTING NUMBER #: 

 

 

VENDOR INFORMATION 

VENDOR REFERENCES: 

VENDOR NAME: 

VENDOR CONTACT: 

VENDOR PHONE #: 

AGENT OFFICE: 

ISO # 

AGENT NAME: 

AGENT PHONE NUMBER: 

                               

 

                                                         PLEASE SEND TO: JL@PAYLOGICSOLUTIONS.COM

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