Merchant Pre-qualification Form

Business Information

Legal or Corporate Name

DBA

Federal Tax ID Number (EIN):

Street Address & Name

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

City or Town

State or Jurisdiction

Postal Zip Code

Telephone Number # at the business physical location

Customer Service Phone Number

Your Mobile Phone #

Your Business Email Address:

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. Ownership (Months /Years)

Primary Contact (Full Name of Owner)

Email Address of owner

Complete Mailing Address *If different from physical address

Describe the products and/or services sold.

Type of Corporate Structure (Choose One)

Sole Proprietor LLC (Limited Liability Company C Corporation S Corporation LLC Partnership Non-profit Trust Government Entity

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.

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

First Name (Principal #1)

Middle Name

Last Name

Social Security Number

Date of Birth (MM/DD/YYYY)

Percentage of Company Ownership (%)

Length of Company Ownership (months/years)

US Government Issued ID#

State of Issuance (name of state)

Residential / Home Address (Street Name & Number)

City, State & Zip Code

Phone Number

ADDITIONAL OWNERS - Are there additional owners? If so, they will need to sign the Service Agreement along with you.

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?

ACH Authorization | Bank Account Deposit Details.

Bank Account Number

Bank Routing

Bank Name

Bank Phone Number#

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Underwriting Profile - Select a box that best describes the type of business profile.

Describe the Methods Used to Capture Sales - Must total 100%

METHODS USED TO CAPTURE SALES - Must total 100%

Average Monthly Processing Volume in US Dollars

Average Sales Ticket

Highest Sales Ticket

Have you accepted credit card 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

WordPress + WooCommerce WordPress + Elementor Divi or WP Cart Shopify Big Commerce SquareSpace Wix.com Weebly Magento Shift4Shop Volusion Ecwid OpenCart PrestaShop GoDaddy Hosting Aweber ActiveCampaign SendInBlue Constant Contact Get Response Campaign Monitor Mailchimp Salesforce Email Studio MailChimp Other

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.
Yes No

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. Provide as much information as possible. After submitting this form, we will email you a Service Agreement that clearly discloses pricing and other deliverables. Sign and return the DocuSign/Service Agreement as soon as possible.

Complete the Merchant Pre-qualification Form. Provide as much information as possible.

After submitting this form, we will email you a Service Agreement that clearly discloses pricing and other deliverables. Sign and return the DocuSign/Service Agreement as soon as possible.