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Company Name
*
Contact Person
*
First
Last
Company Structure
*
--- Select Choice ---
Corporation
LLC (Limited Liability Company)
Partnership
Sole Proprietorship
Joint Venture
Traditional Partnership
Limited Partnership
Limited Liability Partnership
State of Incorporation/Organization
*
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Company Website
Contact Email
*
Contact Phone
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Federal Employer Identification Number (XX-XXXXXXX)
*
If applicable, upload picture of your cancelled check
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Licensing and Compliance Policies (e.g., contractor licenses and customer data protection policies)
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You can upload up to 25 files.
Please provide copies of all final, signed compliance policies, including any regulatory, insurer, or customer notices alleging violations of law or regulation, along with a brief description of any remediation taken (if applicable). Please also provide the following policies and disclosures, as applicable: Privacy Policy; Complaint Policy and complaint log; Compliance Training Policy; Compliance Management System (CMS); Vendor Risk Management Policy or program; Corrective Action Policy; and Audit / Monitoring and Testing Policy. Finally, please provide any customer-facing scripts, disclosures, or materials that will be used in connection with this relationship.
General Liability Insurance
*
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Please provide proof of general liability insurance in an amount commensurate with the risk involved in the conduct and operation of your business.
Merchant Financials
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Audited financial statements may be required for larger merchants or merchants generating significant loan volume, while unaudited financials and tax returns are acceptable for small and mid-sized merchants.
Identification Structure Incorporation/Organization
Signature
*
Clear Signature
I certify all of the above information in this form are true and accurate.
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