FastApply

Legal Entity Address

Name*

Address*

City*

State*

Postal Code*

Contact Phone*

Fax*

DBA Address

Name*

Address*

City*

State*

Postal Code*

Contact Phone*

Fax*

Business Information

Date of Start Business*

# of locations*

Federal Tax Id#*

Mailing Address*

Email*

Website*

Select type of business*

Additional Information for Ownership*

Bankruptcy*

Business*

Personal*

Bankruptcy Date*

Surcharge*

Each individual who owns, directly or indirectly through any contract, arrangement, understanding relationship or otherwise, 25% or more of the equity interests of the Client, or who is the Client’s sole proprietor, must be added.

Primary Owner

Title*

First Name*

Middle Name*

Last Name*

Home Address*

City*

State*

Zip Code*

Home Phone*

Date Of Birth*

SSN*

Type of Document ID*

Driver License / Document ID #*

% Of Ownership*

Guarantor*

Secondary Owner

Title*

First Name*

Middle Name*

Last Name*

Home Address*

City*

State*

Zip Code*

Home Phone*

Date Of Birth*

SSN*

Type of Document ID*

Driver License / Document ID #*

% Of Ownership*

Guarantor*

Third Owner

Title*

First Name*

Middle Name*

Last Name*

Home Address*

City*

State*

Zip Code*

Home Phone*

Date Of Birth*

SSN*

Type of Document ID*

Driver License / Document ID #*

% Of Ownership*

Guarantor*

Fourth Owner

Title*

First Name*

Middle Name*

Last Name*

Home Address*

City*

State*

Zip Code*

Home Phone*

Date Of Birth*

SSN*

Type of Document ID*

Driver License / Document ID #*

% Of Ownership*

Guarantor*

Business Profile

Type of Ownership

Business Type*

Description of Products or Services Sold*

Primary Bank Name*

Transit Routing No.*

Account Number*

Sales Profile

Are you currently accepting VISA/MASTERCARD/DISCOVER® NETWORK?*

Avg. Sale*

Amex Avg. Sale*

Monthly Sales Volume*

Estimate your sales percentage by category. Total must be 100%.

Retail Chip/Swipe*

Imprint (Card Present)*

Mail/Phone*

Internet*

Estimate your sales percentage by category. Total must be 100%.

Sales to businesses*

Sales to consumers*

Sales to goverment*

Pricing Information

Minimum Discount Information

Minimum Amount

$20.00

Discount Type

Daily

Early Termination Fee

ETF Fee

$100.00

ETF Fee Contract Months

Pricing Type

	Per Item	Percent
Service Fee		4.00 %

	Per Item	Percent
Service Fee		4.00 %

	Per Item	Percent
Service Fee		4.00 %

	Per Item	Percent
Service Fee		4.00 %

AUTHORIZATION, MONTHLY & SPECIAL PROGRAM FEES

Name	Per Item
ACH Reject Fee	$ 35.00

Name	Per Item
Chargeback Fee	$ 35.00
Retrieval Fee	$ 35.00

Supporting documents

Copy of your business voided check, using your mobile phone camera or scanned copy in PDF, DOC, DOCX, JPG or PNG format*

Add document

Copy of your state ID, drivers license and/or passport using your mobile phone camera or, scanned copy in PDF, JPG or PNG format*

Add document

I agree with terms and conditions*

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