Merchant Application
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LOCATION INFORMATION
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Legal Name:
Legal Address:
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Legal City
Legal State
Legal Zip
Entity Type:
LLC/Partnership
Corporation - Chapter S, C
Non-Profit
Sole Proprietorship
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Federal Tax ID
Entity Start Date:
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Business (DBA) Name
Business Address
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Business City
Business State
ZIP code
Contact Name:
Location Phone:
Business Email:
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Customer Service Phone:
Fax Number
Website:
Business Information
Products / Services Sold:
Description of Business:
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Product types: ( In additional to your standard inventory please indicate if you sell any of the below products)
CBD
Kratom
Hemp Seeds
Delta, THC, HHC
Please indicate all the items sold at your business so your account can be setup correctly.
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Owner Mobile
*
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Owner First Name:
Owner Last Name:
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Title:
Ownership %
Home Address:
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City:
State:
Zip Code:
Home Phone:
Social Security #:
Date of Birth
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YYYY
2025
2024
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2022
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2020
2019
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2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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2003
2002
2001
2000
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1998
1997
1996
1995
1994
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1983
1982
1981
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1971
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1963
1962
1961
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1959
1958
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1956
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1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
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1938
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Driver License #
DL State:
Driver's License: (To expedite the processing of your application please attach a picture of your driver's license.)
Click or drag a file to this area to upload.
Email:
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Sales Profile
What percentage of your sales are business to business (B2B) and what percentage of your sales are business to consumers (B2C)
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B2B%
B2C %
Processing Volume
Requested Monthly Volume
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Avg Transaction Size
Max Transaction Size
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Avg Monthly Volume
AMEX Annual Volume
Settlement Bank Info
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Bank Name:
Account Number:
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Routing Number:
Type
Savings
Checking
Voided Check: (Please include a picture of a voided check with your business name and address printed by your bank. Your funds will be deposited to this account.)
Click or drag a file to this area to upload.
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