Step 1 of 6
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Merchant Information
Federal Tax ID Number
*
State Tax ID Number
Business Name
*
DBA
Main Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone
*
Fax
Primary Email
Website
Business Structure
*
Choose One
LLC
Partnership
Corporation
Sole Proprietor
Non-Profit
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
*
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth
*
Date Format: MM slash DD slash YYYY
Social Security Number
*
Driver's License Number
*
DL State
*
Choose One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth
*
Date Format: MM slash DD slash YYYY
Social Security Number
*
Driver's License Number
*
DL State
*
Choose One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Percent of Ownership
*
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
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
*
Business Questionnaire
Year Business Established
*
Business Structure
*
Corportation
LLC
Partnership
Sole Proprietor
Non-Profit
Other
State of Company Formation
*
Year of Company Formation
*
Business License Number
License Issued By
Transaction Types
*
Debit and Credit
Debit Only
Credit Only
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
*
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
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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)
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Voided Check or Bank Letter
Copy of preprinted check with merchant name / address or bank account reference on bank letterhead (Escrow / Settlement Account)
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Customer/Investor AML and KYC Policy
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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
Comments
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