High-Risk Paybotx Merchant Agreement

GENERAL INFORMATION - BUSINESS LOCATION, INFORMATION, BUSINESS STRUCTURE
Please name your Sales Agent*
Client Business Name*
(DBA)
Location Address*
(Street Address)
Suite/Floor/Etc.*
City*
State*
Zip Code*
Business Website Address*
Business Phone Number*
Business Email*
example@example.com
Customer Service Phone Number*
Is your Legal Business name different from your DBA?*

YesNo
Is your Legal Business address different from your DBA address?*

Yes, they are differentNo, they are the same
Corporate or Legal Business Name
Corporate Address
Suite/Floor/Etc.
City
State
Zip Code
Legal Phone
Contact Name*
(Owner Name)
Contact Phone Number*
(Mobile/Cellphone)
Federal Tax ID*
Business Start Date*
Indicate Company Structure*

Sole ProprietorshipPartnershipC CorpS CorpTax ExemptLLCGovernment
BANKING ACCOUNT INFORMATION
Bank Name*
Bank Phone*
Routing #*
Account #*
Please upload a copy of a blank or voided check.*

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OWNER INFORMATION
Title*
Ownership Percentage *
Home Address*
Unit*
City*
State*
Zip*
Cell Phone*
Social Security Number*
Date of Birth*
Email Address*
example@example.com
Please upload a copy of your ID.*

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Please upload a copy of your business license*

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TRANSACTIONS INFORMATION
Estimated Monthly Visa/Mastercard/Discovery Card Volume*
Average Ticket Amount*
(What is the amount of your average transaction?)
Highest Ticket Amount*
(What is the amount of your highest transaction?)
Estimated American Express Card Volume*
From the 4 lists below please select the percentage of where the transactions/sales will take place. Please be advised that the combined total of the four lists should equal 100%. Please do not exceed 100% in total.
Card Present Swiped/Chip*
Card Present Manually Keyed*
MOTO*
Internet / Ecommerce*
Business Type*

RetailCharity/Non ProfitPetroleumSupermarketGovernmentLodgingUtilitiesEducationHealthcareRestaurantQSRTelephone OrderB2BInternet
Description of Products or Services Sold*
Accepted Card Types*

Visa Credit/DebitMasterCard Credit/DebitDiscoverAmexPin DebitEBT
Assessments & Brand Fees

Billed SeparatelyIncluded
Requested Discount Payment Method*

DailyMonthly
Wireless Setup Fee
Wireless Monthly Fee
ACH Return Fee
TIN Mis-Match Fee
Is this application for Quickvee POS?

YesNo
Please upload a picture of the business utility bill.*

(include name, business name, and address, utility bill can be water, power, gas)
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Please upload a copy of your business lease agreement or image of your storefront.*

(the image must show DBA (doing business as), suite # or address)
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Initials*
Signature*

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Date*

MonthDayYear
Date
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