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Merchant Enrollment
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Business Name
*
Business Address
*
Address Line 1
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
State
Zip Code
Number of Terminals
Selected Value:
1
Website / URL
Phone
*
Owner Email
*
Owner Name
*
First
Last
Void Cheque
*
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Image of Drivers License Front
*
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W-9
*
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Business Certificate
*
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State/Industry License
*
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ACH Authorization Form
*
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Processing Agreement
*
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Payment Options
*
POB
Pin Debit
Other
Surcharge / Convenience Fee
Selected Value:
3
Additional Comments or Requests
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