Quik Enrollment Form

Merchant Information
Federal Tax ID Number*
Business Name*
DBA
Main Address*
Street Address Address Line 2 City State ZIP Code
Primary Contact Person*
First Last
Primary Contact Title*
Primary Contact Phone*
Fax
Primary Contact Email
Website
Business Structure*
Time in Business*
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*
Percent of Ownership*
Additional Company Principal Information
Name
First Last
Title
Email
Phone
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
Date Format: MM slash DD slash YYYY
Social Security Number
Percent of Ownership
Transaction Info
Estimated Average Ticket Size*
Estimated Monthly Credit Card Volume*
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*

Save and Continue Later

Merchant Information