Merchant Application Form

DBA

Entity Type

Sole Proprietor

Partnership

LLC

Corporation

EIN / TID *

Business Phone *

Company Email Address *

Number of Years in Business

Business Address *

City *

State *

Bank Routing Number

Bank Account Number

Website *

Ticket Average - Price / Sale

$

High Ticket - Price / Sale

$

Processing Average /mo.

$

Business Owner's Full Name *

Cell Phone *

Driver's License # *

Social Security Number *

Driver's License -copy *

.png, .jpeg, .jpg

Front Only

Ownership % *

State Issued *

Home Address

Home City

Home State

Zip Code

2nd Owner Full Name

Owner2 -Percentage

Owner2 Driver's License. Number

Social Security Number -Owner 2

Owner2 -Phone Number

Contact Name ( If different )

Email (If different from Business)

Notes

Advisor l Referring Agent *

(3) Months Bank Statements

(3) Months Merchant Processing Statements

I agree to terms & conditions provided by the company.

Merchant Accounts are referred to and processed by North American Bancard, LLC. North American Bancard, LLC is a registered ISO of Wells Fargo Bank, N.A., Concord Ca., The Bancorp Bank, Philadelphia, PA, and BMO Harris N.A., Chicago, IL. American Express may require separate approval.

Email: paymentsettlement@summitnatadv.com

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