Registration - Savvy Merchant Services

Are you applying for the Cash Discount Program? *

Is a Savvy Merchant Agent helping you with this application? *

Name of Agent

How did you hear about us?

Online Search
Social Media
Business Expo

CONTACT INFORMATION

Name *

First

Last

Email *

Phone Number *

BUSINESS INFORMATION

NOTE: Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations. (See Part IV, Section A.4 of your Program Guide for further information.)

Business Legal Name *

DBA Name *

Tax Filing Name *

Tax Filing Method *

Range *

Type of Ownership *

Government
Individual / Sole Proprietor
Limited Liability Company
Non-Profit Org
Partnership
Private Corporation
Public Corporation
Tax Exempt

Industry (MCC) *

Business Description *

Industry Options

FQuasi Cash

Business Start Date

Website

Business Phone *

Business Address *

Address Line 1

City

State

Zip Code

Business Legal Mailing Address *

Address Line 1

City

State

Zip Code

BUSINESS OWNER INFORMATION

Please provide the following information for each individual who owns, directly or indirectly, 25% or more of the equity interest of your business.

Name *

First

Last

Title *

CEO
CFO
COO
LLC Member
Owner
Partner
President
Secretary
Treasurer
Vice President

% Ownership *

Personal Guarantee

SSN *

Date of Birth *

Mobile Phone *

Email *

Address *

Address Line 1

City

State

Zip Code

ADDITIONAL BUSINESS OWNER (1)

Name

First

Last

% Ownership

SSN

Date of Birth

Mobile Phone

Address

Address Line 1

City

State

Zip Code

DEPOSIT BANK ACCOUNT

Bank Name *

Account Type *

Business Checking
Savings

Routing Number *

Account Number *

Attach Void Check *

Click or drag files to this area to upload. You can upload up to 50 files.

WITHDRAWAL BANK ACCOUNT

Withdrawal account is not required if it is the same as the Deposit account.

Bank Name

Account Type

Business Checking
Savings

Routing Number

Account Number

PROCESSING VOLUME

Average Monthly Card Volume ($) *

per month

Average Transaction Amount ($) *

TYPE OF TRANSACTION (%)

Must total 100%

In Person *

Telephone *

Online *

PRODUCT / SERVICE DELIVERY WINDOWS

On average, Products / Services are delivered in *

0–7 Days
8–14 Days
15–30 Days
30+ Days

NEW ORDERS

Product Name

Network

Qty

Frequency

Product Name 2

Network 2

Qty 2

Frequency 2

Product Name 3

Network 3

Qty 3

Frequency 3

SHIP EQUIPMENT TO MERCHANT SERVICES

Ship To Attention

Ship To Email

Address

Address Line 1

City

State

Zip Code

Savvy Merchant Form Registration

CONTACT INFORMATION

BUSINESS INFORMATION

BUSINESS OWNER INFORMATION

ADDITIONAL BUSINESS OWNER (1)

DEPOSIT BANK ACCOUNT

WITHDRAWAL BANK ACCOUNT

PROCESSING VOLUME

TYPE OF TRANSACTION (%)

PRODUCT / SERVICE DELIVERY WINDOWS

NEW ORDERS

SHIP EQUIPMENT TO MERCHANT SERVICES

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