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Business Name

Operating Address

Address 2

City

State/Zone - Select state -

Postal Code

Contact E-mail

Website Address

Country of Origin - Select country - Albania Algeria Austria Bahrain Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Egypt Estonia Faroe Islands Finland France France, Metropolitan Germany Gibraltar Greece Guernsey Hungary Iceland Iraq Ireland Islamic Republic of Iran Isle of Man Israel Italy Jersey Jordan Kuwait Latvia Lebanon Liberia Liechtenstein Lithuania Luxembourg Macedonia Malaysia Malta Mexico Moldova, Republic of Monaco Montenegro Morocco Netherlands Norway Oman Palestine Authority Poland Portugal Qatar Republic of Serbia Romania San Marino Saudi Arabia Serbia Slovakia Slovenia Spain Sweden Switzerland Syrian Arab Republic Tunisia Turkey United Arab Emirates United Kingdom (Great Britain) United States Yemen

Country of Primary Operations - Select country - Albania Algeria Austria Bahrain Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Egypt Estonia Faroe Islands Finland France France, Metropolitan Germany Gibraltar Greece Guernsey Hungary Iceland Iraq Ireland Islamic Republic of Iran Isle of Man Israel Italy Jersey Jordan Kuwait Latvia Lebanon Liberia Liechtenstein Lithuania Luxembourg Macedonia Malaysia Malta Mexico Moldova, Republic of Monaco Montenegro Morocco Netherlands Norway Oman Palestine Authority Poland Portugal Qatar Republic of Serbia Romania San Marino Saudi Arabia Serbia Slovakia Slovenia Spain Sweden Switzerland Syrian Arab Republic Tunisia Turkey United Arab Emirates United Kingdom (Great Britain) United States Yemen

Address Validation

Voided Check

IRS Form SS-4

Business License

Checking Account

Drivers License

Specialty Licenses

Certificate of Good Standing (for faster approval)

Same as the Business Address

Business Billing Address

Address 2

City

State/Zone - Select state - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Postal Code

Country - Select country - Albania Algeria Austria Bahrain Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Egypt Estonia Faroe Islands Finland France France, Metropolitan Germany Gibraltar Greece Guernsey Hungary Iceland Iraq Ireland Islamic Republic of Iran Isle of Man Israel Italy Jersey Jordan Kuwait Latvia Lebanon Liberia Liechtenstein Lithuania Luxembourg Macedonia Malaysia Malta Mexico Moldova, Republic of Monaco Montenegro Morocco Netherlands Norway Oman Palestine Authority Poland Portugal Qatar Republic of Serbia Romania San Marino Saudi Arabia Serbia Slovakia Slovenia Spain Sweden Switzerland Syrian Arab Republic Tunisia Turkey United Arab Emirates United Kingdom (Great Britain) United States Yemen

LLC Type 2 -- choose option --   Partnership   Corporation   Disregarded Entity  

C Corp Type -- choose option --   Closely Held   Private   Public  

.. -- choose option --   General Partnership   Limited Partnership   Sole Proprietorship   Sub S Corporate   Estate   Trust   Tax Examption Organization   Unincorporated Association   Government   Other  

Other explanation

Specialty License(s) ID

EIN

Year Established

Length of Ownership (yrs & mos)

EBT PIN Debit

EBT Number

Price per Month

Price per Authorization

XBanc Trust Account

Inital Transfer ($)

Mo. Transfer ($)

Cash Incentive

Percent

Wealth Builder

Percent

Interchange Plus

Percent

Per Authorization

Full Name of Primary Owner

Date of Birth

SSN

Current Street Address

Ownership Percentage

Years at Address

Email

City

State - Select state - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

ZIP Code

Previous Street Address (if current is under 2 years)

Years at Address

City

State - Select state - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

ZIP Code

Previous processor

Refund Policy (none, 30days, exchange only, etc.)

Terminal(s) Brand & Model

Terminal(s) --- select option ---   Own   Purchase   Rent  

Quantity

Cost Each

Statement Delivery Preference --- select option ---   Email   Company Address  

Charge Back Delivery Preference --- select option ---   Email   Company Address  

Annual Volume ($)

Average Ticket ($)

Highest Ticket ($)

Projected Monthly Sales

Projected Yearly Sales

Highest Ticket Frequency

According to the Merchant Agreement for Transaction Services, it is necessary for Merchant to provide its banking information to facilitate billing and payments. The Merchant must inform the Processor of any changes to its banking details and accounts. The Processor will not be liable for any funds incorrectly transferred due to a change in banking information or errors that directly resulted from the information provided by Merchant. Merchant authorizes the Processor to debit from the Merchant’s bank account all monthly payments and other amounts owed to the Processor related to the Transaction Services. This authorization shall remain in effect after termination of the authorization shall remain in effect after termination of the Agreement and for as long as Merchant owes any amounts to the Processor. Merchant agrees that the Processor will not be liable for any loss or damage incurred as a result of anything done or not done according to this authorization. If the account is transferred to another branch or the account is closed, and an account is opened at another bank, this authorization shall have the same force and effect as if it originally was directed to that branch or bank. The undersigned Guarantors acknowledge and agree to be bound by all the terms and conditions of this Agreement and unconditionally guarantee the performance of this Agreement. By signing below, Merchant (I) represents that the information provided by Merchant in this Agreement is accurate, complete, and not misleading; (II) acknowledges that Merchant has read and understands this Agreement and Operating Procedures and agrees to be bound by their terms; and (III) authorizes the Processor and its agents to credit and debit the Designated Automatic Funds Transfer Account in accordance with this Agreement. - Select - I attest to the satement above and that I have read and agree to the Service Agreement