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Client Intake Form

    Merchant Info

    Merchant's Legal Name
    Email
    Phone
    Corporate Address
    DBA Name
    DBA Address
    Do you have a website? YesNo
    Website Address

    Business Data

    Federal Tax ID#
    Type of Ownership
    Business Location
    Date Business Started
    Types of goods and services sold

    Business Owner Info

    Business Owner's Home Address
    Business Owner's Phone
    Business Owner's DOB
    First 6 Digits of Business Owner's SS#
    Prior bankruptcies?

    Business Info

    Monthly Card Sales
    Average Ticket
    Highest Ticket
    Deposit Routing #

    Other

    Agent that referred you
    Type of Equipment

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    Our team is ready to assist you in finding the right solution for your business while saving you money on every transaction!

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