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

City*

Home Address*

Floor/Suite*

State*

Zip Code*

Home Phone*

Date Of Birth*

SSN*

Type of Document ID*

Driver License / Document ID #*

% Of Ownership*

Email*

Guarantor*

FICO Score*

Secondary Owner

Title*

First Name*

Middle Name*

Last Name*

Address Search

City*

Home Address*

City*

State*

Zip Code*

Home Phone*

Date Of Birth*

SSN*

Type of Document ID*

Driver License / Document ID #*

% Of Ownership*

Email*

Guarantor*

FICO Score*

Third Owner

Title*

First Name*

Middle Name*

Last Name*

Address Search

City*

Home Address*

City*

State*

Zip Code*

Home Phone*

Date Of Birth*

SSN*

Type of Document ID*

Driver License / Document ID #*

% Of Ownership*

Email*

Guarantor*

FICO Score*

Fourth Owner

Title*

First Name*

Middle Name*

Last Name*

Address Search

City*

Home Address*

City*

State*

Zip Code*

Home Phone*

Date Of Birth*

SSN*

Type of Document ID*

Driver License / Document ID #*

% Of Ownership*

Email*

Guarantor*

FICO Score*

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?

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*

Annual Sales Volume*

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

Retail Chip/Swipe*

Imprint (Card Present)*

Mail/Phone*

Internet*

Transaction Information

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

Business-to-Business*

Business-to-Consumer*

Business-to-Government*

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*

Pricing Information

Minimum Discount Information

Minimum Amount

$ 25.0000

Discount Type

Daily

Early Termination Fee

ETF Fee

$ 500.0000

ETF Fee Contract Months

Pricing Type: Cash Discount

	Rate	Cash Discount
	3.84 %	3.99 %

AUTHORIZATION, MONTHLY & SPECIAL PROGRAM FEES

Name	Per Item
Chargeback Fee	$ 25.00
Retrieval Fee	$ 15.00

Name	Per Item
ACH Reject Fee	$ 25.00
PCI Non-compliance Fee	$ 19.95

Standard Fees

Name	Per Item
Next Day Funding	$ 0.00

Supporting documents

Copy of your state ID, drivers license and/or passport using your mobile phone camera or, scanned copy in PDF, JPG or PNG format

Add State ID

Copy of your business voided check, using your mobile phone camera or scanned copy in PDF, DOC, DOCX, JPG or PNG format

Add Voided Check

I agree with Terms and Conditions*

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