Merchant Account Pre-application

Complete the Merchant Pre-qualification Form in its entirety.

After submitting this form, our preferred payment processor will email you a DocuSign Agreement. Sign and return the DocuSign as soon as possible.

BUSINESS INFORMATION

Business Name (exactly as it appears on your federal income tax return)

Legal or Corporate Name (must match IRS filing name)

Doing Business As (DBA) Name

Federal Tax ID Number (EIN):

Street Address & Name (*the physical business operating address, not a P.O. Box. Home-based businesses are acceptable).

Apt.# / Suite # /Bldg.# / Unit# (Optional)

State or Jurisdiction

Telephone Number # at the business physical location.

Number of Physical Locations

Customer Service Phone Number (with area code)

Business Website URL Domain (www.__________________________)

Business Start Date; Month & Year Date (MM/DD/YYYY)

Length of Ownership (Months /Years)

Industry SIC Code *If known. Leave blank if unknown.

Primary Contact (Full Name)

Primary Email Address

Complete Mailing Address *If different from physical address

Describe the products and/or services sold.

Type of Corporate Structure (Select One)

State or Jurisdiction of Corporate Registration

Is the applicant a foreign business? If so, indicate the country/nation where the business is registered AND provide the business license #number. *Have a copy of the business license ready submission to our underwriters.

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OWNERS and OFFICERS
*The person signing this merchant agreement must have at least 51% ownership interest in the company.

First Name (Principal #1)

Social Security Number

Date of Birth (MM/DD/YYYY)

Percentage of Ownership (%)

US Government Issued ID#

State of Issuance (name of state)

Citizenship (If Not USA)

Length of Company Ownership (months/years)

Residential / Home Address (Street Name & Number)

City, State & Zip Code

ADDITIONAL OWNERS (Provide details on an additional owner/co-owner or partner holding 25% or more controlling interest)

Are there additional owners or managing partners holding 50% or greater ownership interest in this company? If the answer is yes, these persons will be required to send in a color copy of a valid government-issued ID and sign the final Service Agreement.

No Yes

Percentage of Ownership (%)

Date of Birth (MM/DD/YYYY)

City, State & Zip Code

Email Address of co-owners

Social Security Number

Length of Ownership (months/years)

US Government Issued ID #

Citizenship (If Not USA)

ACH AUTHORIZATION | BANK DEPOSIT DETAILS.
*Identify the bank where funds shall settle for deposit. Must be a valid checking account with a USA domestic bank or credit union.

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UNDERWRITING PROFILE: Select a box that best describes the type of business profile.

Merchant Type:

Estimated Average Monthly Processing Volume in US Dollars

Average Sales Ticket

Highest Sales Ticket

METHODS USED TO CAPTURE SALES - Must total 100%

Credit Card Swiped % Keyed Entry / Manual Entry % Mail Order / Telephone Order % Internet

HAVE YOUR ACCEPTED CREDIT CARDS BEFORE?

Yes No

If yes, under what business name?

Name of Current of Previous Payment Processor?

In the past, has a credit card processor wrongfully terminated your merchant account without first giving you advance written notice and perhaps withheld funds or frozen funds? If yes, please provide the name of credit card processor and a brief explanation.

PROVIDE THE NAME OF YOUR WEBSITE BUILDER

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TECHNICAL DETAILS:
Please share with us or explain any unique technical requirements or equipment related details to better prepare the Technical Support Team to meet your service integration needs.

Do you need a credit card swipe terminal or point-of-sale device? Select yes or no.

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REQUESTED PROCESSING PARAMETERS

Average Sales Ticket Amount $

Average Monthly Processing Volume $

Highest Sales Ticket Amount $

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TERMS & CONDITIONS OF ACCEPTANCE
This Merchant Account Pre-Qualification form is not a binding contract for service. Information provided in this form allows the ISO and Merchant Services Providers to assess and pre-vet for the applicant for the most suitable product. Furthermore, all information provided in this form is considered private and confidential in nature. Under no circumstances will your data be sold to or shared with any outside party that has no direct involvement in the provisioning of service.

SERVICE DISCLAIMER & LIABILITY WAIVER
Under no circumstances does submission of an application for a merchant account guarantee approval of service. The ISO/sales agent shall will not be held financially responsible nor liable for any costs, fees, business expenses or any losses if an application for a merchant account is declined.

INDEMNIFICATION & WAIVER OF RISK & LIABILITY
Merchant/Applicant agrees to indemnify, defend, and hold harmless KJ Proweb, its officers, directors, agents, employees, and suppliers from and against any lawsuit, claim, liability, loss, penalty or other expense (including attorneys’ fees and cost of defense) they may suffer or incur as a result of a bank or MSPs inability to delivery merchant processing services as described in a Enrollment Application for Service. If you, the merchant/applicant do not agree with nor accept this Indemnification and Waiver of Liability in its entirety, do not apply for service.

Complete the Merchant Pre-qualification Form in its entirety.

After submitting this form, our preferred payment processor will email you a DocuSign Agreement. Sign and return the DocuSign as soon as possible.

Got questions? Call our sales and support team at (818) 850-1034

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