Create Client

Account Information

First Name

Company Name

Last Name

Mobile

Timezone

Username

Password

Confirm

Verify Code

Business Information

Legal Business or Corporate Name

Do Business as Name

Physical Address

City

State

ZIP

Billing Address

City

State

ZIP

Business Website URL

Business Phone

Business Fax

Other Phone

Date Formed

Years In Business

Number Of Locations

Federal Tax ID

State Tax ID

Sales Tax ID

Business Description (Be Specific)

Type Of Business

Mail Order

Inbound Phone

Internet

Retail

Outbound Phone

Other

Contact Name

Title

Contact Email

Contact Phone

Guarantor Information

Primary Officer/Owners Name

Title

Equity Ownership %

Social Security No

Date of Birth

Residence Address

City

State

ZIP Code

Residence Phone

Years At Addr

Own/Rent (check One)

Own

Rent

Personal Email Address

Primary Officer/Owners Name

Title

Equity Ownership %

Social Security No

Date of Birth

Residence Address

City

State

ZIP Code

Residence Phone

Years at Address

Own/Rent (check One)

Own

Rent

Personal Email Address

Financial Institution Information

This is the account that will be credited and debited.

Financial Institution Name

Back Officer Name

Phone

Addr

City

State

ZIP Code

Name on Account

Bank ACH Routing No

Bank Account No

Customer Information Request

Does your company offer ACH processing?

Yes - Please mark all that apply below:

Debit Trans

Creadit Trans

Remote Deposit Capture (RDC)

Remotely Created Checks (RCC)

No - Proced to Section 6

Which NACHA SEC Codes does your company originate (Complete requested volumes for all that apply)

PPD ?

CCD ?

Average Debit Transaction Size ($)

Average Credit Transaction Size ($)

Average Daliy Debit Settlement ($)

Average Daliy Credit Settlement ($)

Peak Daliy Debit Settlement ($)

Peak Daliy Credit Settlement ($)

Returns as a % of Avg. Daliy Debits ($)

Returns as a % of Avg. Daliy Debits (#)

Unauthorized Returns % of Avg. Daliy Debits ($)

Unauthorized Returns % of Avg. Daliy Debits (#)

Previous Year

Year of Date

a. Annual Volumes: What were the transaction volume total dollar amounts, total number of transactions and average amount of ACH debits processed by company?

Total Volume $

Total #

Average Amount $

b. Annual Volumes: What were the transaction volume total dollar amounts, total number of transactions and average amount of ACH credits processed by company?

Total Volume $

Total #

Average Amount $

c. Annual Volumes: What were the total volume of ACH returns what is percentage rate of Returns based on total volume of ACH Payments and what is the actual-loss volume and actual-loss rate percentage?

Return Rate

Actual Loss Rate

d. Does company require merchants/clients to prefund credit payments

Yes

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