Online Merchant Application

Legal Entity Address

Name*

Address Search

Address*

City*

State*

Postal Code*

Contact Phone*

Fax*

DBA Address

Name*

Address Search

Address*

City*

State*

Postal Code*

Contact Phone*

Fax*

Business Information

Date of Start Business*

# of locations*

Federal Tax Id#*

Mailing Address*

Email*

Website*

Select type of business*

Are you selling CBD/Delta 8/10/HHC etc, Nutraceuticals or Kratom?*

Do you provide massage services?*

Are you selling Gas or Fuel?*

Additional Information for Ownership*

Bankruptcy*

Business*

Personal*

Bankruptcy Date*

Fees Program

Each individual who owns, directly or indirectly through any contract, arrangement, understanding relationship or otherwise, 25% or more of the equity interests of the Client, or who is the Client‘s sole proprietor, must be added.

Primary Owner

Title*

First Name*

Middle Name*

Last Name*

Address Search

Home Address*

City*

State*

Zip Code*

Home Phone*

Date Of Birth*

SSN*

Type of Document ID*

Driver License / Document ID #*

% Of Ownership*

Email*

Guarantor*

Secondary Owner

Title*

First Name*

Middle Name*

Last Name*

Address Search

Home Address*

City*

State*

Zip Code*

Home Phone*

Date Of Birth*

SSN*

Type of Document ID*

Driver License / Document ID #*

% Of Ownership*

Email*

Guarantor*

Third Owner

Title*

First Name*

Middle Name*

Last Name*

Address Search

Home Address*

City*

State*

Zip Code*

Home Phone*

Date Of Birth*

SSN*

Type of Document ID*

Driver License / Document ID #*

% Of Ownership*

Email*

Guarantor*

Fourth Owner

Title*

First Name*

Middle Name*

Last Name*

Address Search

Home Address*

City*

State*

Zip Code*

Home Phone*

Date Of Birth*

SSN*

Type of Document ID*

Driver License / Document ID #*

% Of Ownership*

Email*

Guarantor*

Business Profile

Type of Ownership

Business Type*

Description of Products or Services Sold*

Description Refund / Return Policy*

Do you want to open Netevia Banking account?

Or enter manually

Select Checking Account*

Primary Bank Name*

Transit Routing No.*

Account Number*

Sales Profile

Are you currently accepting VISA/MASTERCARD/DISCOVER® NETWORK?*

Avg. Sale*

Max. Sale*

Monthly Sales Volume*

Estimate your sales percentage by category. Total must be 100%.

Retail Chip/Swipe*

Imprint (Card Present)*

Mail/Phone*

Internet*

Estimate your sales percentage by category. Total must be 100%.

Sales to businesses*

Sales to consumers*

Sales to goverment*

Netevia Banking Account

First Name*

Middle Name*

Last Name*

Address Search

Street Address*

City*

State*

Zip*

Email*

Phone*

Date Of Birth*

SSN*

Authorized Person Title*

Percentage Ownership*

Employer Identification Number*

I agree with Terms and Conditions*

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