signupbyrep Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Agent Name *JanetEthanVickieLisaChrisAgent Email *Merchant InformationProposal Number *Legal Entity Name (LLC, Sole Proprietor, Corp) *Year Legal Entity Formed *DBA *Federal Tax ID (EIN)Business PhoneBusiness Email *Business AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLegal Entity AddressSame as Business AddressLegal Entity AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeOwner InformationOwner Name *FirstLastOwners CellEmail *Home AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSocial Security #Date of BirthDriver's License Number and Issuing State (copy)Percent OwnershipAdditional Owners?NoYesOwner 2 InformationOwner 2 Name *FirstLastOwner 2 CellOwner 2 Email *Owner 2 Home AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeOwner 2 Social Security #Owner 2 Date of BirthOwner 2 Driver's License Number and Issuing StateOwner 2 Percent OwnershipHardware/Processing InformationType of BusinessRestaurant/BarRetail/GroceryType of Restaurant POSTonic – Processing by BoldSpotOnCash Register (ECR) – Processing by BoldStandalone Processor – Processing by BoldEBT/WIC? *YesNoType of Retail POSOctoposStandalone Processor (Bold)Direct or Capital *DirectCapitalType of Processing *Cash DiscountFlat RateIC +Daily or Monthly Fee Withdrawal? *DailyMonthlyRateMonthly SaaSInstall FeePromotion?Processors Selected Value: 1 Type of Processor *StandardWirelessTerminals Selected Value: 1 Cash Drawers Selected Value: 1 Customer Facing Display Selected Value: 0 Receipt Printer Selected Value: 1 Kitchen Printer Selected Value: 0 KDS Selected Value: 0 Additional Printers Selected Value: 0 Integrated Processor Selected Value: 0 a920 Selected Value: 0 a77 Selected Value: 0 Tablet Selected Value: 0 Scale Selected Value: 0 Scanner Selected Value: 0 Label Printer Selected Value: 0 Notes & UploadsComment or MessageVoided Check Click or drag a file to this area to upload. Drivers License Click or drag a file to this area to upload. Copy of Menu Click or drag files to this area to upload. You can upload up to 10 files. Logo Click or drag files to this area to upload. You can upload up to 3 files. Submit
