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 Phone:
*
Product:
*
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
FEE SCHEDULE (SCHEDULE A)
OTHER FEES
Authorization Fee
$
5.00000
BATCH FEE
$
0.00000
Transaction Fee
$
0.00000
Chargeback Fee
$
25.00000
Monthly Dashboard Access Fee
$
0.00000
Retrieval Fee
$
5.00000
Voice Authorization/IVR Fee
$
0.00000
AVS Transaction Fee
$
0.00000
Monthly Minimum Fee
$
20.00000
Monthly Fee
$
10.00000
Application Fee
$
0.00000
Other
Include Fee Type and Billing Method (One time, monthly, etc.)
Annual Fee
$
0.00000
0.00000
Billing Method:
One Time
Monthly PCI Fee
$
5.00000
Billing Method:
Cash Discount. Duo Price:
Rent Fee:
Print Name:
*
Co-Application:
Form Date:
Upload Files:
Copy of Driver’s License
Copy of Voided Check
Signature:
*
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