New Merchant Information Form

DBA Name *

DBA Address *

City/State/Zip *

DBA Phone *

Email Address *

Legal Name *

Legal Address (if different from DBA)

City/State/Zip

Product/Service *

Est Monthly Volume

Est Average Ticket

Highest Ticket

Ownership Type

LLCCorporationSole ProprietorPartnership

Date Business StartedMM/DD/YYYY

Social Security #

Date of BirthMM/DD/YYYY

Owner Name *

Home Address

City/State/Zip

Phone/Cell

Any other principals with 25% ownership? If so, please submit their info also.

Other principals (25%+ ownership)List name, ownership %, and contact details for any additional principals.

Bank Name *

Merchant Legal Name *This is the legal name that you registered your business as. Please be sure that this is correct.

Federal Tax IDThis is the 9-digit number that was assigned to you when you registered your business.

Bank Account #/DDA

Transit Routing #

Bank Account Type *

Merchant Information

1. Do you currently accept credit card payments?

YesNo

Service Request

2. What do you need?

Terminal Programming (TPN/Reprogram)New Payment TerminalPayarc Mobile App

Terminal Connection

3. What type of terminal connection would you like?

Ethernet / BroadbandWi-Fi4G Cellular (+$19.95/month)

Tipping Options

4. Would you like to enable tipping?

No TipsYes – Tip Line OnlyYes – Suggested Tip Amounts Printed on ReceiptYes – Suggested Tip Amounts Displayed on Screen During Checkout

Employee Tracking

Invoice & Order Numbers

5. Would you like the ability to enter invoice or order numbers with transactions?

YesNo

Sales Tax

6. How would you like sales tax handled?

Add tax to each transactionTax is already included in the transaction amount

SMS & Email Receipts

7. Would you like to include a custom message on SMS or email receipts?

YesNo

Printed Receipt Signature

8. Would you like a signature line printed on customer receipts?

YesNo

Receipt Header

9. Would you like a custom message printed at the top of your receipts?

YesNo

Attachments

Driver's license (optional)

(attach driver's license — PDF or image)Voided check (optional)

(attach voided check)

The information supplied will be used to complete the Merchant Processing Agreement. This form does not constitute a contract or agreement to do business with the Merchant Processor.

Owner signature:

Sign here