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Business Information

Agents Name
Agents #
Type
POS?
POS Monthly
Monthly
Website?
Cash Discount Rate
Subtype

Rate

Credit
Debit

NQ Rate

NQ Credit
NQ Debit
Transaction Fee
Credit Fee
Debit Fee
Credit Q
Credit MQ %
Credit MQ $
Credit NQ %
Credit NQ $
Debit Q
Debit MQ %
Debit MQ $
Debit NQ %
Debit NQ $
Other items
Full Stations
Station Price
$ 
0.00
Licenses
License Price
$ 
0.00
Kitchen Printers
Printer Price
$ 
0.00
Need Extras?
Extras
Analog / VOIP
Price
0.00
Number of side terminals
Price
0.00
Number of hand held:
Price
0.00
Number of Scales
Price
0.00
Number of Scanners
Price
0.00
Please select Merchant
VAR
Dejavoo
Gateway
POS Monthly:
POS Setup:
Website Setup:
Website Downpayment:
Website Recurring:
Website Monthly
Media Design:
Logo Design, Flyer Design, Business Card, Poster etc
Type of Ownership
Legal Business name
TAX ID
Business Email
Date Business Started
DBA
Address
Business Phone
Monthly Payment
Annual Revenue

Additional information

Second Owner ?

Owner 1

First Name
DOB
Last Name
Personal Email
Home Address
SSN
Cell PH#

Owner 2

First Name 2
Dob 2
Last Name 2
Personal Email 2
Home Address 2
SSN 2
Cell ph# 2

Financial Info

Bank Name
Bank Acccount #
Bank Routing #
Voided Check
Maximum file size: 8 MB
Driving License
Maximum file size: 8 MB
SS4 Doc
Maximum file size: 8 MB
Merchant Previous Statement
Maximum file size: 8 MB
0.00
0.00
Additional Notes ?
Additional Notes