Apply – PayTrac NYC

Agent Information

Completed by the submitting agent.

Agent Name

Agent Phone

Agent Email

Business Information

Business DBA(Required)

Business Legal Name(Required)

DBA Address(Required)

Street Address City State ZIP Code

DBA Phone Number

DBA Fax Number

Corporate Address

Street Address City State ZIP Code

If different from the DBA address.

Email Address(Required)

Website URL

Tax Filing Name

Tax ID #(Required)

Federal Tax ID / EIN

Business Start Date

Products or Services Sold

Ownership Type

Ownership Information

Owner Name(Required)

First Last

Title

Ownership %

Please enter a number from 0 to 100.

Date of Birth(Required)

SSN(Required)

Home Address(Required)

Street Address City State ZIP Code

Primary Phone

Mobile Phone

Owner Email

Is there an additional owner?

No

Yes

Additional Owner

Second Owner Name

First Last

Second Owner Title

Second Owner Ownership %

Please enter a number from 0 to 100.

Second Owner Date of Birth

Second Owner SSN

Second Owner Phone

Second Owner Email

Second Owner Home Address

Street Address City State ZIP Code

Processing Information

Annual Card Sales Volume - Mastercard/Visa(Required)

Annual Card Sales Volume - Amex

Annual Card Sales Volume - Discover

Average Sale

Highest Sale

Retail %

Please enter a number from 0 to 100.

In-person

MO/TO %

Please enter a number from 0 to 100.

Keyed / mail and phone order

Internet %

Please enter a number from 0 to 100.

E-commerce

MCC #

EBT FNS #

Amex SE #

Discover SE #

Equipment Information

Terminal Name

Qty

POS / Gateway Name

Virtual Terminal

No

Yes

Tips

No

Yes

Auto Settle Time

Banking Information

Bank Name

Account Type

Checking

Savings

Bank Account #(Required)

Bank Routing #(Required)

Portfolio Information

Approximate number of current merchants

Processing platforms used

POS most used

What would you like a card partner to do better?

Required Documents

Please attach a valid copy of the signer's photo ID, a voided check or bank letter, and your EIN / SS-4 letter.

Voided Check or Bank Letter(Required)

Accepted file types: pdf, jpg, jpeg, png, heic, Max. file size: 264 MB.

Driver's License or Photo ID(Required)

Accepted file types: pdf, jpg, jpeg, png, heic, Max. file size: 264 MB.

EIN / SS-4 Letter

Accepted file types: pdf, jpg, jpeg, png, heic, Max. file size: 264 MB.

Underwriting Notes

Merchant Application

Agent Information

Business Information

Ownership Information

Additional Owner

Processing Information

Equipment Information

Banking Information

Portfolio Information

Required Documents

Company

Programs

Contact