Complete one page application, then go to signature page.

Owner first name:

Owner last name:

Email address:

Business Phone:

Doing business as name (DBA):

This is the name that your customers will see on their credit card statements.

Legal business name:

Company Ownership:

Please Select Sole Proprietorship Corporation LLC Partnership Non-Profit Government Tax Exempt

Business address:

Street address only. No P.O. Boxes.

Business city:

Business state:

Please Select 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

Business zip code:

Owner home address:

Street address only. No P.O. Boxes.

Home city:

Home state:

Please Select 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

Home zip code:

Home phone:

Example 555-555-5555

Owner title:

Please Select Owner President CEO Vice President Secretary/Treasurer Managing Member Partner

Date of birth:

Date of birth of principal. Example 10/22/72.

Ownership percentage:

Please Select 0% 100% 99% 98% 97% 96% 95% 94% 93% 92% 91% 90% 89% 88% 87% 86% 85% 84% 83% 82% 81% 80% 79% 78% 77% 76% 75% 74% 73% 72% 71% 70% 69% 68% 67% 66% 65% 64% 63% 62% 61% 60% 59% 58% 57% 56% 55% 54% 53% 52% 51% 50% 49% 48% 47% 46% 45% 44% 43% 42% 41% 40% 39% 38% 37% 36% 35% 34% 33% 32% 31% 30% 29% 28% 27% 26% 25% 24% 23% 22% 21% 20% 19% 18% 17% 16% 15% 14% 13% 12% 11% 10% 9% 8% 7% 6% 5% 4% 3% 2% 1%

Select percentage of ownership.

Owner social security number:

Enter your 9 digit social security number.

Business federal tax ID number:

Enter your 9 digit Federal Tax ID number.

How long have you been in business?:

Year(s)

Month(s)

Please enter numeric value.

Type of merchant:

Please Select Retail Restaurant Mail & Phone Internet Lodging Petroleum

Description of business premises:

Please Select Store Front Office Home Trade Shows Mobile

Business products/services sold:

Example: Office products, Electronics, Landscaping.

How much will your average credit card transaction be?:

$

Example: $20, $100, $500

How much do you expect to process in total credit card volume each month?:

$

Example: $2,000, $5,000, $20,000

What credit card terminal or internet software would you like to process transactions with?:

Select Virtual Terminal LFRCO Gateway LFRCO API Other Not Sure

Bank name where we will be depositing your funds:

Bank Routing Number:

Routing # is always a 9 digit #. See check example below.

Bank Account Number:

Account # varies in length by financial institution. See check example below.

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