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
