ChargeToday Merchant Application

Merchant Application

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Welcome to the ChargeToday Merchant Application

Fill out the application below.

Applicant Information

Please fill out all fields on the form including places which may be seem to be duplicates, as they fill different pages on the application. Do not use "same as above" or "unknown" for required fields.

Legal Business Name (Corp / LLC / Etc) *

Doing Business As (only if different than Business Name above)

Physical Address (Address, City, State, Zip, NO PO BOXes) *

Mailing Full Address (Address, City, State, Zip)

Primary Applicant's Phone *

Primary Applicant's Email *

Primary Applicant's First Name *

Primary Applicant's Last Name *

Fax Phone

Website

Select Type of Business Structure *

Select

Individual/Sole Proprietor
Partnership
Corporation
Limited Liability Company (LLC)
Non-US Entity
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Federal Tax ID Number *

Hours Of Operation *

Year Established *

States Licensed / License # *

Customer Service Email *

Customer Service Phone *

Principal / Officer / Manager

Fill out the following information for the primary owner of the company.
Other owners with 25% or more ownership will be listed later in the application.

Controlling Manager - Full Name *

Controlling Manager - Title *

Controlling Manager - Full Address (Address, City, State, Zip) *

Controlling Manager - Work Phone Number *

Conrolling Manager - Mobile Phone *

Controlling Manager - SSN *

Controlling Manager - Date of Birth *

Controlling Manager - Drivers License State and Number

Controlling Manager - Drivers License Expiration

Percentage of Ownership *

Authorized Representative

The names of employees listed below are vested by the merchant with full authority to access the payment processing account.

Authorized Rep 1 - Full Name *

Authorized Rep 1 - Title *

Authorized Rep 1 - Phone *

Authorized Rep 1 - Email *

Authorized Rep 2 - Full Name

Authorized Rep 2 - Title

Authorized Rep 2 - Phone

Authorized Rep 2 - Email

Additional Required Information:

Has any company, principal, officer, manager or authorized representative:

been indicted, arrested or convicted of any crime other than minor traffic violations during the past ten years? *

Yes

No

been the subject of an administrative hearing by any Department or Agency of the Federal Government or any State Government during the past ten years? *

Yes

No

Filed for Bankruptcy? *

Yes

No

Is any company, principal, officer, manager or authorized representative:

A Senior Executive of a Foreign Owned Business *

Yes

No

A Senior Foreign Political Figure or family member of a Senior Political Figure? *

Yes

No

if any of the questions above in this section were marked YES please provide a detailed description of the circumstances:

Additional Owners To Add

Are there any additional owners with more than 25% ownership of the compaby

For the application, it must be signed by all owners of the company with more than 25% ownership. Please list those names below.

Is there another owner to add? *

Yes

No

Owner 2 - Full Name *

Owner 2 - Title *

Owner 2 - Full Address *

Owner 2 - Ownership Percentage *

Owner 2 - Work Phone *

Owner 2 - Mobile Phone *

Owner 2 - SSN *

Owner 2 - Drivers License Number & State *

Owner 2 - Drivers License Expiration *

Owner 2 - Date of Birth *

Is there another owner with more than 25% ownership?

Yes

No

Owner 3 - Full Name *

Owner 3 - Title *

Owner 3 - Full Address *

Owner 3 - Ownership Percentage *

Owner 3 - Work Phone *

Owner 3 - Mobile Phone *

Owner 3 - SSN *

Owner 3 - Drivers License Number & State *

Owner 3 - Drivers License Expiration *

Owner 3 - Date of Birth *

Is there another owner with more than 25% ownership? *

Yes

No

Owner 4 - Full Name *

Owner 4 - Title *

Owner 4 - Full Address

Owner 4 - Ownership Percentage

Owner 4 - Work Phone

Owner 4 - Mobile Phone

Owner 4 - SSN

Owner 4 - Drivers License Number

Owner 4 - Drivers License Expiration & State

Owner 4 - Date of Birth

Is there another owner with more than 25% ownership? *

Yes

No

Owner 5 - Full Name

Owner 5 - Title

Owner 5 - Full Address

Owner 5 - Ownership Percentage

Owner 5 - Work Phone

Owner 5 - Mobile Phone

Owner 5 - SSN

Owner 5 - Drivers License Number & State

Owner 5 - Drivers License Expiration

Owner 5 - Date of Birth

For settlements, deposits and fees, enter your bank information below:

Bank Routing # *

Bank Account # *

Type of Bank Account *

Checking

Savings

Are there any other DBA (doing business as) names to add to the application? *

Yes

No

DBA Name 2

DBA Name 3

DBA Name 4

DBA Name 5

Please check your application for accuracy before submitting, as it will be what is used to generate your document to be electronically signed.

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Once complete, you will also need the

following items scanned and ready to send:

Preprinted voided check or bank letter
W-9
Copy of Business License
Government Issued Identification
Three Months Business Bank Statements
One Year Business Financials

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