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Application (1)

Step 1 of 4

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Comments
This field is for validation purposes and should be left unchanged.
Front Cover Sheet
Business (DBA)(Required)
Contact First Name(Required)
Contact Last Name(Required)
Business Phone #(Required)
Business Address(Required)
City(Required)
State(Required)
Zip(Required)
Rep Number
SelectivePay Account Type(Required)

Company Information
DBA Name(Required)
Contact Name
DBA Address Type(Required)
DBA Address 1(Required)
(No PO Box)
DBA Address 2
Country(Required)
State(Required)
Province
City(Required)
Zip(Required)
All Address Checkbox
- Use this address for all future addresses (mailing, billing, etc.)
Country Of Formation(Required)
Country Of Primary Business Operations(Required)
DBA Phone #(Required)
Email Address(Required)
DBA Fax #
Year Established(Required)
Current Ownership (years)(Required)
Please enter a number from 0 to 99.
Current Ownership (months)(Required)
Please enter a number from 0 to 99.
Mobile Phone #
Beneficial Owner Exemption(Required)
Other Addresses
Other Addresses
- No Additional Addresses
- Mailing
- Shipping
Mailing DBA Name
Mailing Contact Name
Mailing Phone #
Mailing Fax #
Mailing Address
Mailing City
Mailing State
Mailing Zip
Shipping DBA Name
Shipping Contact Name
Shipping Phone #
Shipping Fax #
Shipping Address
Shipping City
Shipping State
Shipping Zip
Statements / Retrievals / Chargebacks
Statement Format
- Electronic
- Paper
Statements
- DBA
- Mailing
- W-9
Retrievals
- Mail Retrievals
- Fax Retrievals
- Email Retrievals
- Online Case Management
Email Retrievals to
Chargebacks
- Mail Chargebacks
- Fax Chargebacks
- Email Chargebacks
- Online Case Management
Email Chargebacks to

Principal 1 Information -- Include all additional owners with 25% or greater ownership (individual or intermediary business)
Beneficial Owner: Percentage of ownership(Required)
Please enter a number from 0 to 100.
Sole Proprietor
- Sole Proprietor
- Authorized Signer
Additional Beneficial Owners(Required)
Responsible Party(Required)
- Responsible Party
- Personal Guarantee
Title
First Name(Required)
Middle Name
Last Name(Required)
Address Type(Required)
Address (No PO Box)(Required)
City(Required)
Country(Required)
Zip/Postal Code(Required)
State(Required)
Province
Address current for 2 years
- This address is current for 2 years or longer
DOB(Required)
Month
Day
Year
Country of Citizenship(Required)
Phone Number
Previous Address if Current Address is Less Than 2 Years
Previous Address
City
State
Zip/Postal Code
ID Type(Required)
ID #
Other Company Information
Average Sale Amount (in USD)(Required)
High Sale Amount (in USD)(Required)
Number of Annual High Sales(Required)
Total MONTHLY Visa/MC/AMEX/DISC/UnionPay Sales (in USD)
Card Present %
Card Not Present %
Internet %
Describe When Product is Received
Product Website
"Contact Us" Email
Annual Revenue in USD(Required)
Industry Type(Required)
Customer Service Phone #
Previous Processor
Description of Product/Services Offered(Required)
Special Program MCC Only
When is product received? (In days)
Seasonal Product
- This is a seasonal company
If seasonal, please check every month your company is closed below.
Months Closed
- January
- February
- March
- April
- May
- June
- July
- August
- September
- October
- November
- December

Bank Account (Checking accounts only)
Deposit Bank Name(Required)
ABA/Routing #(Required)
DDA Account #(Required)
Billing Account
- I use a different bank account for billing
Billing ABA/Routing #(Required)
Billing DDA Account #(Required)
Chargeback Account
- I use a different bank account for chargebacks
Chargeback ABA/Routing #(Required)
Billing DDA Account #(Required)
Card Acceptance
Cards Accepted
(Please check each card you wish to accept)
- All Card Types
- Visa Credit
- Visa Debit
- MasterCard Credit
- MasterCard Debit
- Discover
- UnionPay
- AMEX
Substitute Form W-9
Business Type
- Sole Proprietor
- Public Corp
- Closely Held Corp
- Sub S Corp
- Government
- General Partnership
- Limited Partnership
- Tax Exempt Organization
- Estate
- Unincorporated Association
- Trust
- Private Corp
- Limited Liability Co
LLC Tax Classification(Required)
Tax Exempt Status Document Upload
Max. file size: 32 MB.
Legal Business Name
(Name of business as shown your business income tax returns. For Sole Proprietors, this should always be the owner's name.)
Legal Business Address (No PO Box)
City
State
Zip
TIN (Employer ID #)(Required)
TIN (Social Security #)(Required)
Deposit Slip or Voided Check
Max. file size: 3 GB.
Business License
Max. file size: 3 GB.
Drivers License
Max. file size: 3 GB.
Merchant Statement
Max. file size: 3 GB.
Please attach your most recent merchant statement.
Terms and Conditions
- I have read and agree to the terms and conditions
Signature
Your Name
Your Name
Your Name

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