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SCG Payments- Merchant Application

Take Online Payments! Get started today.

1Getting Started

2Business Information

3Shareholder/Owner 1

4Shareholder/Owner 2

5Primary Control Contact

Sales Agent

Name *

First

Middle

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

BUSINESS INFORMATION:

DBA (Doing Business As) Name: *

Business/Corporate Name: (as shown on your Income Tax Return) *

Location Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Is the mailing address the same as the physical address? *

Statement Mailing Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone Number: *

Business Fax Number:

Email *

Website / URL

Banking Information

Bank Name:

Name on Bank Account:

Checking Account #:

Bank Routing #:

Federal Tax ID:

TIN Type

Bank Account Contact Name:

Merchant Account Information

Type of Merchant

Sole Proprietor
Partnership
LLC
Corporation
Non-Profit
Other

Statement Option Type:

Electronic
Paper

Business Processing Category:

MOTO
Retail
Restaurant
Internet
Other

Merchandise/Services Sold:

Years in Business:

Currently accept Visa/MasterCard/Discover/AXP?

Seasonal Merchant:

Percent of Business: (must equal 100%)

Card Swipe: %

Manually Keyed: %

Phone/Mail Order: %

Internet: %

Total: 100 %

Avg Ticket:

High Ticket:

Avg Monthly Volume:

High Monthly Volume:

Transaction Descriptor to Appear on Cardholder's Statement:

Customer Service Phone Number to Appear on Cardholder's Statement:

OWNERS AND OFFICERS: List all owning 25% or more business equity. Use addendum to list additional

Total Number of owner, shareholders, partner

1 Owner/Shareholder
2 to 3 Owners/Shareholders
More than 3 Owners/Shareholders

Shareholder/Owner 1

Name:

Title:

Applicant's SS#:

Date of Birth:

Equity Ownership:

Residence Address:

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Shareholder/Owner 2

Name:

Title:

Applicant's SSN#:

Date of Birth:

Equity Ownership:

Residence Address:

Address Line 1

Address Line 2

City

State

Zip Code

Phone

PRIMARY CONTROL CONTACT: List person responsible for control management of account (CEO, COO, Manager, etc.).

Name:

Residence Address:

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth:

SSN#:

I certify that the information provided is true to the best of my knowledge.

Signature

Disclaimers

SCG Financial, Inc is a registered DBA of EPX, a registered ISO of BMO Harris Bank N.A., Chicago, IL, Fresno First Bank, Fresno, CA, and Citizens Bank N.A., Providence, RI.

SCG Financial, Inc is a license insurance broker in the Commonwealth of Virginia and an affiliate of Shalom Consulting Group, LLC, Fredericksburg, Virginia and may received a commission for insurance financial products through appointed insurance carriers listed (link).

Shalom Consulting Group is a license insurance consulting firm in the Commonwealth of Virginia and charge a fee for insurance consulting services.

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