Cash Advance
Merchant Services
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System
Merchant Services Questionnaire
We install the equipment for free to process payments for your clients.
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Print
If you do not want to fill out this digital form you can choose to fill it
out by hand thenscan and send by mail. Please Download or Print.
All fields marked with
*
are required
Sent Application
Agent:
BUSINESS INFORMATION
Business Name
*
DBA (If different):
*
Business Type:
Select Business Type
Corp
LLC
Sole Prop
LP
Business Tax ID:
*
Business Start Date:
*
Business Address - Street:
*
City:
*
State:
*
Zipcode:
*
OWNER INFORMATION
Contact Name:
*
Owner’s Name y Title:
Email:
*
@
Phone:
*
Building Type:
Location:
Owner Address - Street:
City:
State:
Zipcode:
Owner's DOB:
Owner Social:
*
DL #:
Owner’s Percent of Ownership of Business:
OTHER INFORMATION
Monthly Volumen:
$
.00
Average Ticket:
$
.00
High Ticket:
$
.00
Products/Services Solid:
Swipe:
$
%
Keyed:
$
%
Internet:
$
%
Monthly Fee:
$
%
Cash Discount. Duo Price:
Select if it is with a Cash Discount
Yes
No
Rate:
$
%
Tran Feet:
$
%
EBT:
$
%
Terminal:
Print Name:
*
Co-Application:
Form Date:
Upload Files:
Copy of Driver’s License
Copy of Voided Check
Signature:
*
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