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Business Information
Business Name
Opersating Address
Address 2
City
State/Zone
- Selecciona provincia -
Postal Code
Contact E-mail
Website Address
Country of Origin
- Selecciona país -
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
- Selecciona país -
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
Reqired Documentation Checklist
Billing Address
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Voided Check (please upload)
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IRS Form SS-4
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Busniess Licence
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Checking Account
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Owner's Drivers License
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Specialty Licences
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Certificate of Good Standing (for faster approval)
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Business Billing Information
Same as the Business Address
Business Billing Address
Address 2
City
State/Zone
- Selecciona provincia -
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
- Selecciona país -
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
Business Legal Designation
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 Services
EBT PIN Debit
EBT Number
Price per Month
Price per Authorization
Additional Services
XBanc Trust Account
Inital Transfer ($)
Mo. Transfer ($)
Cash Incentive
Percent
Wealth Builder
Percent
Interchange Plus
Percent
Per Authorization
Owner Information
Full Name of Primary Owner
Date of Birth
SSN
Telephone
Current Street Address
Ownership Percentage
Yrs. on Address
Email
City
State
- Selecciona provincia -
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)
Yrs. on Address
City
State
- Selecciona provincia -
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
Processing information
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
Processing Information
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.
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I attest to the satement above and that I have read and agree to the Service Agreement
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