Merchant Registration

Please fill complete the form below. For the quickest response rate from our team, make sure to include all of the optional fields in your submission

Online Merchant Application

Please complete each of the 3 sections below, any required fields are marked with an * next to the field name. When you are done, click Submit Registration.

Company Name: *
DBA: *
Tax ID: *
Merchant Category Code: *
Corp Structure: *
Entity Formation Date: *
At Location Date: *
Address: *
Address 2:
City: *
State: *
Zip: *
Separate Mailing Address
Bank Name: *
Name on Account: *
Route #: *
Account #: *
Company Description: *
Phone: *

Title: *
Full Name: *
Phone: *
Email: *
SSN: *
% of Ownership: *
Address: *
Address 2:
City: *
State: *
Zip: *
DL Number: *
DL State: *
DL Issue Date: *
DL Exp Date: *
Date of Birth: *
Responsible Individual

By checking this box and proceeding with your registration you are agreeing to the following:

That you are an authorized individual affiliated with the Legal Entity applying for this Service and you have provided the name, address, date of birth and Social Security Number (or Passport or other similar information for non- US persons) for the Beneficial Owner(s) of the Legal Entity applying for this Service. For the purpose of this registration, a Beneficial Owner is an individual, if any who owns, directly or indirectly 20 percent (per Bank’s Policy) or more of the equity interests of the Legal Entity customer, or an Individual with significant responsibility for managing the Legal Entity customer (e.g. CEO, COO, Managing Member, President, Vice President, Treasurer). A Legal Entity includes a corporation, Limited Liability Company, or other entity that is created by filling of a public document with the Secretary of State or similar office, a general partnership, and any similar business entity formed in the United States or foreign country.

That you have provided your consent allowing the Bank to perform due diligence which may include no less that the following; 1)Validating the identity of the legal entity including the Beneficial Owner(s), 2) Performing a credit check on the Beneficial Owner(s), and 3) Originating a small dollar ACH transaction to your funding account.

Accept Credit Cards

Projected monthly volumes provided during registration.

Average Ticket ($): *
Max Ticket ($): *
Volume ($): *
Volume AMEX ($): *
Trans (#): *
Refunds (#): *
CB (#): *

Method of acceptance (should equal 100%).

% Swiped: *
% Keyed (MO/TO): *
% Internet: *
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Please fill in all the required fields.
Registration Submitted
Thank you for registering. Please check your email for instructions on how to proceed.
Gateway Monthly Fee:
CC Item Fee:
CC Basis Point:
ACH Item Fee:
ACH Basis Point:
ACH Return Fee:
RDC Item Fee:
RDC Basis Point:
RDC Return Fee: