Merchant agreement #3260
General Business Information
Contacts
Product/Services Information
General Business information
Company / Legal Name
DBA
Website
Location Address
City
State
Zip
Mailing Address
City
State
Zip
Contacts
Primary
Phone
Email
Technical
Phone
Email
Billing
Phone
Email
Compliance
Phone
Email
Customer Service Phone #
Customer Service Email
Organization
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LLC
Corporation
Proprietor
Partnership
Federal Tax ID#
# of locations under this Tax ID
Business Site
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Office
Retail
Residence
Website
Has the merchant and/or principal owner(s) had a bank account frozen or forcefully closed in the past 5 years?
Has the merchant and/or principal owner(s) filed for bankruptcy or defaulted on debts in the past 5 years?
Does the merchant do business in foreign countries?
Does the merchant engage in internet gambling activities?
Has the merchant or any affiliates, subsidiaries or related companies in the last five years related to the service provided been subjected to litigation or regulatory action?
Has any owner plead guilty or been convicted of any felonies
Business Reference
Company
Contact Name
Contact Email
Contact Phone
Product/Services Information
Describe the products and services offered
Please explain how payment authorization is collected
Lenders Only
Please describe how you market to new customers for your loan products. This should include, but not limited to, direct mail, buying leads, outbound phone calls, etc.
Name of Loan Management System
State Lenders Only Max APR% charged for each state
The undersigned certifies the accuracy of all the foregoing information is true and complete and that they have the authority to make the application for the company. Company authorizes FLEX PAYMENT SOLUTIONS and its providers to use any and all such information to perform a review of the information for requested services, including access to personal credit files.
Authorized Signature
Date
Printed Name
Title
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