ACHQ KoreConx Application • ACH & eCheck Processing with ACHQ

Merchant Information
Federal Tax ID Number*
State Tax ID Number
Business Name*
DBA
Main Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Fax
Primary Email
Website
Business Structure*
Time in Business*
Trade Reference
Please complete the below with information from an unrelated company that you regularly do business with.
Company Name*
Contact Person*
Phone*
Business Type*

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Primary Contact Person
Name*
First Middle Last
Title*
Email*
Phone*
Company Principal Information
Name*
First Middle Last
Title*
Email*
Phone*
Home Address*
Same as Company

Street Address Address Line 2 City State ZIP Code
Date of Birth*
Date Format: MM slash DD slash YYYY
Social Security Number*
Driver's License Number*
DL State*
Percent of Ownership*
Additional Company Principal Information
Name*
First Middle Last
Title*
Email*
Phone*
Home Address*
Same as Company

Street Address Address Line 2 City State ZIP Code
Date of Birth*
Date Format: MM slash DD slash YYYY
Social Security Number*
Driver's License Number*
DL State*
Percent of Ownership*

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Projected Transaction Volume
Average Single Transaction*
Max Single Transaction*
Transactions Per Month*
Average Monthly Volume*
Max Monthly Volume*
Statement Details
Display Name*
Phone*
Product Details
Product*
Delivery*
Refunds*
Marketing Methods*
- Inbound Customer Calls
- Outbound Customer Calls
- TV
- Website
- Print
- Internet Ads
- Direct Mail
- Other
Other

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Settlement Bank Account Details
Where you want your payments deposited
Bank Name
Account Number*
Routing Number*
Billing Bank Account Details
Where you want your fees debited
- Same as Settlement Account
Bank Name
Account Number
Routing Number*
Bank Reference
Bank Name*
Contact Person*
Phone*
Account Number*

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Business Questionnaire
Year Business Established*
Business Structure*
State of Company Formation*
Year of Company Formation*
Business License Number
License Issued By
Transaction Types*
Customer Service Phone*
Customer Service Hours*
Products Offered*
Websites
Customer Types*
- Business
- Consumer
Percent from Consumer
Have you accepted credit card payments in the past?*
- Yes
- No
Previous Processor*
Have you received complaints from the Better Business Bureau, Attorney General or similar organization?*
- Yes
- No
Please provide details of Complaints*
Have Merchant, Owners, or Principals ever filed business bankruptcy or personal bankruptcy?*
- Yes
- No
Please provide details of bankruptcy inclding the date and jurisdiction where the case was filed*

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Notice and Terms
Typed Name of Submitter*
Email Address
Document Upload
Please upload the documents below and press the "submit" button to submit your application for processing. If the documents are not available at this time, you can either click "Save and Continue Later" to come back to this page at a later time and upload the documents, or click "Submit" and we will reach out to you to collect the documents as we process the application.
Authorized Signer's Photo ID
Drop files here or
Bank Statements
Most recent consecutive 6 months prior bank statements (Operating / Business Account)
Drop files here or
Processing Statements
Most recent consecutive 6 months prior processing statements
Drop files here or
Business Formation Documents
Articles of Incorporation or other corporate governance documents that evidence ownership
Drop files here or
Marketing Matierials
Copies of relevant advertisements, marketing materials and sales practices
Drop files here or
Business Financials or Tax Returns
Most recent CPA prepared corporate financial statements AND / OR Tax Returns. Tax returns must include supporting schedules Financial statements must include income statements and balance sheets
Drop files here or
Sample Investment Statement or "Receipt"
Copy of document received by investor upon purchase of share(s)
Drop files here or
Voided Check or Bank Letter
Copy of preprinted check with merchant name / address or bank account reference on bank letterhead (Escrow / Settlement Account)
Drop files here or
Customer/Investor AML and KYC Policy
Drop files here or
Company Executive Summary
Drop files here or
FinCEN Beneficial Ownership Confirmation*
Please upload the completed document provided to you by KoreConx. If you do not have a copy the document is linked below.
Drop files here or
Financial Licensing
Any relevant licensing from SEC, FINRA, etc.
Drop files here or
Beneficial Ownership Confirmation Form Download
Name
This field is for validation purposes and should be left unchanged.

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Step 1 of 6

Merchant Information

Trade Reference

Primary Contact Person

Company Principal Information

Additional Company Principal Information

Projected Transaction Volume

Statement Details

Product Details

Settlement Bank Account Details

Billing Bank Account Details

Bank Reference

Business Questionnaire

Notice and Terms

Document Upload