Sales Rep: Adrian Gonzalez

Contact Information

Contact Name

Email Address

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Mobile Phone

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Business Information

Business Type

Company Legal Name

Company DBA Name

Do you have an EIN (Tax ID) number?

Yes

Tax ID (EIN)

Physical Business Address

Street Address

Zip Code

City

State

Is your physical address and mailing address the same?

Yes

Corporate / Mailing Business Address

Street Address

Zip Code

City

State

Business Description

Business Phone

Fax

Website Address

Industry Type

What CRM Software do you use?

Is your personal credit over 635?

Yes

Describe your experience in the Credit Repair field

Mention previous work experience, any webinars, seminars, courses or certification you achieved – be as descriptive as poissble

Business History

Business Established On

Have you ever accepted credit cards before?

Yes

With Whom?

Have you ever been terminated from processing?

Yes

Please tell us what happened

Processing Parameters

Monthly Volume

Average Ticket

Highest Ticket

Sales Method (Must Equal 100%):

Card Present (Swipe / EMV)

Card Not Present (Keyed)

Field must be a number between 0-100, both fields together must equal 100.

Bank Information

Routing Number

Account Number

Bank Name

Personal Information

First Name

Last Name

Title

Ownership Percentage

Business Physical Address and Home Address are the same?

Home Address

Zip Code

City

State

How long do you live in this address for? (in Years)

Home Phone

Social Security Number

Date of Birth

Signer must be at least 18 years old

Driver License State

Driver’s License Number

Email Address

Do you want to add another signer / principal?

Yes

Principal 2 Information

First Name

Last Name

Title

Ownership Percentage

Business Physical Address and Home Address are the same?

Home Address

Zip Code

City

State

How long do you live in this address for? (in Years)

Home Phone

Social Security Number

Date of Birth

Signer must be at least 18 years old

Driver License State

Driver’s License Number

Email Address

Please use a different email address for second principal.

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Phone

Operating System

Web Browser

Message

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855-891-2600 ext 2012

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Let’s create your account.

Contact Information

Business Information

Business History

Processing Parameters

Sales Method (Must Equal 100%):

Bank Information

Personal Information

Principal 2 Information

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