Our mission is to provide great service to the clients. One way we try to do that is to create a clear understanding with each other. The purpose of this form is to define our agreement and to communicate information needed:
Please complete the following application.
INSTRUCTIONS:
Please fill in all the fields as complete as you can.
Fields marked with a red asterisk ( * ) are requiredBusiness Information (do NOT use a P.O. Box for Business Address)
*Business Name (DBA):
*Business Legal Name:
*Business Address:
*City, State, Zip:
,
*Country:
*Contact Name:
*Business Phone #:
- -
*Business Fax:
- -
*E-Mail Address :
*Web Address (URL):
Ownership Information
*Principal Owner/Officer #1:
*% Ownership: (If less than 50%, Official Officers form must be generated)
*Title:
*Home Address:
*City, State, Zip:
,
*Home Phone #:
- -
*Social Security Number:
###-##-####
*Date of Birth:
/ /
Principal Owner/Officer #2
% Ownership: (If less than 50%, Official
Officers form must be generated)
Title:
Home Address:
City, State, Zip:
,
Home Phone #:
- -
Social Security Number:
###-##-####
Date of Birth:
/ /
Business Information
*Type of Business:
*Industry:
*Year Established:
*Current Ownership # Yrs:
*Current Ownership # Mos:
*Federal Tax ID #: (If sole proprietorship is checked above, the SSN goes here)
Business Checking Account Information
*Bank Name:
*Address:
*City, State, Zip:
,
*Phone #:
- -
*Business Checking Account Number:
*Routing/Transit Number:
*Average Credit Card Ticket:
$
*Monthly Credit Card Volume:
$
Additional Information Required
*Your customer service phone #:
- -
*How did you hear about us:
*What products or services do you sell:
*Please choose the store that you want: (Pick only one):
Total Package Gateway
*In which time zone is the business located:
*Do you experience high volume seasonal sales: (Yes or No):
Yes No
Do you have experience in a similar business?
If yes, how many years:
*Have you or the business been party to any claims or lawsuits?: (Yes or No):
Yes No
*Have you or the business declared bankruptcy?: (Yes or No):
Yes No
Please check other cards to be accepted: (a processing fee will be charged for each card checked)
American Express Discover
Notes:
This until you:
1. Fax us a copy of the signed ACH Authorization along with your Voided Company Check. (ACH is an automatic withdrawal of your checking account.) A link to this document will be included in the email you receive after you submit this application. (Fax Number 212-591-6112)
2. Fax and mail the signed portion of the Web Design Agreement (you will receive this link in the email you receive after you submit this application)
3. Send us a copy of Marketing Materials or have a Web Site with DBA name, refund policy and customer service phone number all prominently displayed.
