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Pre-Application Form – Business Services
Requested Services
Full Name:
*
Title/Position:
Date of Birth:
Email address
*
Home Address:
SSN (9 digits):
Driver’s License Number:
State / Expiration Date:
Select
Rate Your Personal Credit
Excellent (720+)
Good (680–719)
Fair (640–679)
Poor (below 640)
Unsure / I don't know
Check all that apply
Please select at least one option.
Visa/MasterCard
American Express
Discover
Debit
ATM Machine
Payment Gateway
Mobile App
Virtual Terminal
Business Information
*
DBA (Doing Business As):
Phone Number:
Email Address:
Business Address:
City / State / ZIP:
Business Start Date
Percentage of Ownership in the Business
Website:
Tax ID (9 digits):
Products or Services Sold:
Average Ticket Amount ($):
Method of Sales Used in the Business
Please select at least one option.
In-person (storefront or office)
Online / eCommerce
Phone sales
Mobile / On-site services
Subscription / Recurring billing
Other: ___________
Estimated Monthly Sales Volume ($):
Type of Payment Processor Used
Please select at least one option.
Square
Clover
Stripe
PayPal
Toast
Authorize.Net
Other: ______________
Message
E-Signature (Full Name):
Date
File upload
Service Request
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