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Home/Connect Payment/Apply for Connect Payment Merchant account

Business Information

Business Name

Operating Address

Address 2

City

State/Zone

Postal Code

Contact E-mail

Website Address

Country of Origin

Country of Primary Operations

Reqired Documentation Checklist (please upload)

Address Validation

Voided Check

IRS Form SS-4

Business License

Checking Account

Drivers License

Specialty Licenses

Certificate of Good Standing (for faster approval)

Upload file

Business Billing Information

Same as the Business Address

Business Billing Address

Address 2

City

State/Zone

Postal Code

Country

Business Legal Designation

LLC Type 2 -- choose option -- Partnership Corporation Disregarded Entity

C Corp Type -- choose option -- Closely Held Private Public

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

Years at Address

City

State

ZIP Code

Previous Street Address (if current is under 2 years)

Years at Address

City

State

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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