Pre-Application Please fill out the information below to complete the pre-application process. Please allow one to two business days for processing. Please enable JavaScript in your browser to complete this form.Sales AgentFirstLastSales Agent EmailLegal Name / Corp Name *Tax ID / SS#DBA NameBusiness Start DateType of Ownership Sole ProprietorPartnershipLLCCorporationNon-ProfitGovernmentPhysical Address *Street AddresssCity *StateZipMailing Address (if different from physical address)Street AddresssCityStateZipLegal Address (if different from other address)Street AddresssCityStateZipDescription of Product and/or Service *EBT NumberAnticipated Monthly Volume *Average Transaction AmountHighest Transaction AmountBank NameLast 4 Digits - Account NumberOwner Legal Given Name *FirstLastDate of BirthOwner Social Security NumberOwner Email Address *Owner Home AddressCityStateZipOwner Drivers License # or State IDOwner ID's State of Issue% of Ownership2nd Owner Legal Given NameFirstLastDate of Birth2nd Owner Social Security Number2nd Owner Email Address2nd Owner Home AddressCityStateZip2nd Owner Drivers License # or State ID2nd Owner ID's State of Issue2nd % of OwnershipTerminalsSelect...FD130VX520PAXS80FD150QuantityPinpadsSelect...Clover StationClover MobileClover MiniClover GOFD35 (works with FD130)QuantityEquipment Pricing NotesOther information needed to set up accountConnection TypeSelect...IPWirelessDial-UpFile TypeSelect...RetailResturantOtherOther OptionsPin DebitEBTCash BackTipsReport OptionsTotal ReportsDetail ReportsBothAuto BatchYesNo(if yes) Auto Batch TimeSelect...0100 - 1 am0200 - 2 am0300 - 3 am0400 - 4 am0500 - 5 am0600 - 6 am0700 - 7 am0800 - 8 am0900 - 9 am1000 - 10 am1100 - 11 am1200 - 12 NOON1300 - 1 pm1400 - 2 pm1500 - 3 pm1600 - 4 pm1700 - 5 pm1800 - 6 pm1900 - 7 pm2000 - 8 pm2100 - 9 pm2200 - 10 pm2300 - 11 pm2400 - 12 MIDTime ZoneSelect...US Pacific TimeUS Mountain TimeUS Eastern TimeBR Rio de Janeiro, BrazilGB London, UKDE Berlin, GermanyRU Moscow, RussiaAE Dubai, United Arab EmiratesIN Mumbai, IndiaSG Singapore, SingaporeCN Beijing, ChinaJP Tokyo, JapanAU Sydney, AustraliaNZ Auckland, New ZealandAccount TypeTraditionalCash DiscountCredit RatesSelect...PassthroughTieredFlat RateIC + (enter % below)+ (enter $ below)Qualified %Mid-Qualified %Non-Qualified %Transactional $$ per transactionor % per transactionPin DebitSelect...PassthroughFlat RateIC + (enter % below)+ (enter $ below)$ per transactionor % per transactionEBT Flat Rate - $ per transactionContract TermsSelect...Month to Month24 Months5 YearsCash Discount PricingSelect...$0/terminal$19/terminal$29/terminal$39/terminal$59/terminal$99/terminal$129/terminalOther (see notes below)Additional Cash Discount/Surcharge account info.Traditional Processing RatesSelect...Terms within proposalOther (see notes below)Additional Traditional Processing account info.Additional Cords Needed?Select...Yes (see notes below)NoIf additional cords add notes here.Additional Signage Needed?Select...Yes (see notes below)NoInfo for additional signage.Additional Notes & ShippingSend copy of pre-application to sales agent email?YesNoSubmit
