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Merchant Information
Disclosures and Acceptance
Ownership Certification
W-9
Attachments
Merchant Application Agreement
Legal Information (as listed with the state registration)
Legal Name*
Legal Business Name as listed with the IRS
Legal Address*
Legal Business Address as listed with the IRS
Legal City*
Legal State*
Choose One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Legal Zip*
Legal Contact Name*
Legal Email*
Legal Phone*
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Principal Information (Owners Information)
Principal Name*
Title*
Ownership Percentage*
Home Address*
Address should match what's on your current Drivers License
Home City*
Home State*
Choose One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Home Zip*
Date of Birth*
/
/
Cell Phone*
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Social Security Number*
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Tax Information
Ownership Type*
Choose One
Corporation
LLC
Sole Proprietorship
Partnership
Tax Exempt
Other
Business Type
Corporation
LLC
Sole Proprietorship
Partnership
Tax Exempt
Other
Federal Tax ID*
-
If Sole Proprietor enter your SSN here
Month Opened*
Choose One
January
February
March
April
May
June
July
August
September
October
November
December
Year Opened*
Choose One
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
Merchant Information
Same as Legal Address
Same as Legal Address
NOTE: The merchant address must be a physical street address, not a P.O. Box
DBA Name*
DBA Address*
DBA City*
DBA State*
DBA Zip*
Merchant Contact*
Merchant Email*
Merchant Phone*
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