ACHQ Merchant App v2

Step 1 of 4

25%

Hidden

Send Plaid Email

Business Details

Legal business name*

Tax ID*

Doing business as*

This name will appear on your customer's statements.

Industry*

Type of business*

Website*

Phone*

Business and product/service description*

Describe your customers and the products or services you offer.

Business address*

Street Address Address Line 2 City State ZIP Code

Contacts and Owners

Beneficial Owner Name*

First Last

This must be an individual with greater than 25% ownership or significant management responsibilities (CFO, CTO, etc.)

Job title*

Email*

Cell phone*

Social Security Number*

Ownership Percent*

Date of birth*

MM slash DD slash YYYY

Home Address*

Street Address Address Line 2 City State ZIP Code

Add an additional company representative?

Yes

Authorized Representative

Name

First Last

Title

Company Phone

Does this individual own 25% or more of the business?

Yes

Social Security Number

Ownership Percent

Payment Processing

Tell us about your current and projected processing volume.

Dollars / month*

Transactions / month*

Max single transaction*

Max daily amount*

Returned transaction %*

Hidden

Average Transaction Amount*

Customer types*

Consumer

Business

Transaction types*

Debits

Credits

Authorization method(s)*

PPD

CCD

WEB

TEL

How to authorize ACH

ACH Descriptor*

We already pass along your company name and phone number, so consider some other value here.

Customer service phone*

This number will appear on your customer's statements

Customer service email*

Use of ACH*

Examples include payroll, service fees, sale of goods, subscription fee, tuition, etc.

Refund/Return Policy*

Financing/Loan Details

Funding Recpient

Average Loan Amount

Average Loan Term

Average Loan APR

Max Loan Amount

Max Loan Term

Max Loan APR

Banking Details for Settlements

Bank name*

Routing number*

Account number*

Use this account for fees?*

Yes

Billing Bank Account Details

Where you want your fees debited

Billing bank name

Billing routing number

Billing account number

Signature and agreement

Agreement

I consent to the ACH Payment Services Agreement, the Acceptable Use Policy, and the Electronic Signature Terms, and I am providing written instructions under the Fair Credit Reporting Act authorizing ACHQ, to obtain and use information from my personal credit report to process this application.

This inquiry will not affect your credit score.

Signature

Typed name of signee

Signature

Comments

This field is for validation purposes and should be left unchanged.