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Owner Information

First Name*

Last Name*

Phone number*

Email*

Social Security Number*

Date of birth*

Home address*

Home City*

Home State*

Home zip code*

Cell Number*

Legal business name*

Business Information

Business Phone number*

Business Type*

Business Address*

Business City*

Business State*

Business Zip Code*

Connection type*

Year Founded

Average Ticket

Do you want tips?*

Auto Batch Time*

Total Monthly Card Volume*

High Ticket*

EIN Federal Tax ID #*

EBT FSN #

Bank & Deposit Information

Accept WEX/Fleet Cards?*

Sales Tax Rate Per Sale

Name on Deposit Account*

What Is Your Rep's Name?*

Bank Name

Routing Number

Account Number

Sales Agent

Upload Documents

⬆️

Driver’s License

PDF or images, up to 4 files

⬆️

Voided Check

PDF or images, up to 4 files

⬆️

Bank Statement

PDF or images, up to 4 files

⬆️

Merchant Statement

PDF or images, up to 4 files