Online Merchant Application

Legal Entity Address

Business Name*

Street Address*

Floor/Suite*

City*

State*

Zip Code*

Phone*

DBA Address

Business Name*

Street Address*

Floor/Suite*

City*

State*

Zip Code*

Phone*

Fax*

Business Information

Mailing Address*

Prior Security Breach*

Email*

Web Site*

Federal Tax Id*

Number of Locations*

Type of Ownership*

Date of Start Business *

Date of Start Owned Business *

Tax Type*

Tax Filing Name*

D&B Number*

I certify that I am a foreign entity/nonresident alien. (If checked, please attach IRS Form W-8)*

Select type of business*

Fees Program

Additional location to existing MID*

Each individual who owns, directly or indirectly through any contract, arrangement, understanding relationship or otherwise, 25% or more of the equity interests of the Client, or who is the Client‘s sole proprietor, must be added.

Owner's Information

Title*

First Name*

Last Name*

City*

Residence Street Address*

Floor/Suite*

State*

Zip Code*

Home Phone*

Country Of Citizenship*

Date Of Birth*

Applicants SSN*

Equity Ownership, %*

Type Of Issued ID*

ID Number*

ID Expiration Date

Email*

Owner's Information

Title*

First Name*

Last Name*

City*

Residence Street Address*

Floor/Suite*

State*

Zip Code*

Home Phone*

Country Of Citizenship*

Date Of Birth*

Applicants SSN*

Equity Ownership, %*

Type Of Issued ID*

ID Number*

ID Expiration Date

Email*

Trade Reference

Business Name*

Business Address*

City*

State*

Zip Code*

Contact Name*

Phone*

Account #*

Business Profile

What goods or services do you provide?*

Type Of Merchant*

Primary Operation Country*

Current Processor*

Have you filed for bankruptcy?*

ACH Method*

Bankruptcy Date

Personal*

Business*

Reason for leaving*

Banking Information

Do you want to open Netevia Banking account?

Where should we deposit your processing funds?

Bank Name*

Name on Bank Account*

Routing/Transit Number*

Account Number*

Bank Phone*

Netevia Banking Account

First Name*

Middle Name*

Last Name*

Address Search

Street Address*

City*

State*

Zip*

Email*

Phone*

Date Of Birth*

SSN*

Authorized Person Title*

Percentage Ownership*

Employer Identification Number*

Transaction Profile

Estimate your sales percentage by category. Total must be 100%.

Card Swipe/Chip*

Manual Key Entry Or Imprint*

Mail/Phone Order*

Internet*

Transaction Volume

Monthly Sales Volume*

Avg. Sale*

Max. Sale*

Transaction Information

Estimate your sales percentage by category. Total must be 100%.

Sales to consumers*

Sales to businesses*

Sales to goverment*

Has Been Terminated*

Reason For Termination*

American Express and Debit Options

Amex Status*

Amex ID*

Monthly Card Volume*

Average Card Ticket*

Highest Card Ticket*

Accept Debit Transactions*

Accept EBT Transactions*

FCS Number*

Currently Accepting EBT Food Stamps*

EBT Cash Benefit Number*

Third Party

Are you using a third party to store, process or transmit cardholder data?*

Give name/address: (examples include, but not limited to hosting companies, shopping carts, Loyalty Programs, Electronic Data Capture)*

Please identify the software name and version used for storing, transmitting or processing Card Transaction or Authorization requests*

Pricing Information

Pricing Type

	Credit Card	Debit Card
Cash discount service fee	3.99%	3.99%
Per Item

	Credit Card	Debit Card
Cash discount service fee	3.99%	3.99%
Per Item

	Credit Card	Debit Card
Cash discount service fee	3.99%	3.99%
Per Item

	Credit Card
Cash discount service fee	3.99%
Per Item

Supporting documents

Copy of your state ID, drivers license and/or passport using your mobile phone camera or, scanned copy in PDF, JPG or PNG format

Add State ID

Copy of your business voided check, using your mobile phone camera or scanned copy in PDF, DOC, DOCX, JPG or PNG format

Add Voided Check

I agree with Terms and Conditions*

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