Brian Miller
National Card Payments
brian@kbcardprocessing.com
Direct:
8016990486
SIGN UP FOR
Processing
1.
Business Name
"Doing business as" Name
?
Legal Name of Business
?
2.
Business Physical Address
?
Street
City
State
-- Select State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
3.
Business Legal Address
?
Click here if same as physical address
Street
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
4.
Mailing Address
Click here if same as physical address
Street
City
State
-- Select State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
5.
Other Business Info
Business Phone #
Customer Service Phone # (click here if same as business phone #)
?
Website Address
Year Business Established
Federal Tax ID # (EIN)
?
Business Entity Type
Disregarded Entity
Corporation
Partnership
Sole Proprietor
Limited Partnership
Public Corp
Sub S Corp
Closely Held Corp
General Partnership
Government
PLLC
Non Profit
6.
Financial Information
Deposit Bank Name
?
Bank 9 Digit Routing Number
?
Checking Account Number
7.
Account Contact Person
Name
?
Email Address
8.
Application Signer Information
Click here if address is the same as owner #1
Full Name of Signer
Social Security Number
Percentage of Ownership
Date of Birth (mm/dd/yyyy)
Cell Phone Number
Street
City
State
Zip Code
Are there any other owners with 25% or more ownership?
Yes
No
Owner #1
Full Name of Signer
Social Security Number
Percentage of Ownership
Date of Birth (mm/dd/yyyy)
Cell Phone Number
Street
City
State
-- Select State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Are there any other owners with 25% or more ownership?
Yes
No
9.
Signer's U.S. State Drivers License, or State ID, or Passport
Document ID #
Issue Date (mm/dd/yyyy)
Date of Expiration (mm/dd/yyyy)
State where document was issued
-- Select State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
10.
Processing Information
Average Credit Card Transaction Amount (in dollars)
High Single Credit Card Transaction Amount (in dollars)
Number of Times Per Year High Single Transaction Amount Occurs
Average Monthly Credit Card Sales Volume (in dollars)
Total Company Annual Sales (in dollars)
What Product and/or Services Are Being Sold?
How Many Days Until Product and/or Services is delivered?
Submit Form
Thank you!