ACH / eCheck Application

Business information

Legal business name *Owner's personal name if sole proprietor

DBA

EIN (or SSN if sole proprietor)

Business start date

Business phone

Customer support phone

Hours of operation

Business physical address, city, state, zip

Mailing address, city, state, zip (if different)

Website

Will the website be used to obtain authorization for payments?

Yes No

Contact

Contact name *

Email *

Phone

Text-enabled

Settlement bank account

Name on account

Bank name

Account type

Personal Checking Personal Savings Business Checking Business Savings

Routing (ABA) number

Account number

Branch phone (optional)

Branch address (optional)

Separate billing routing # (optional)

Separate billing account # (optional)

Referral

Referred by (optional)Name of the referral agent or partner who introduced you, if any.

List at least one corporate officer, plus every owner with 25% or more. SSNs can be left blank and provided at signature.

Owner / officer 1

Full name *

Title

Ownership %

Date of birth

SSN

Driver's license / ID number

State

Home address, city, state, zip

Home / mobile phone

Phone is text-enabled

Owner / officer 2

Full name

Title

Ownership %

Date of birth

SSN

Driver's license / ID number

State

Home address, city, state, zip

Home / mobile phone

Phone is text-enabled

Owner / officer 3

Full name

Title

Ownership %

Date of birth

SSN

Driver's license / ID number

State

Home address, city, state, zip

Home / mobile phone

Phone is text-enabled

Owner / officer 4

Full name

Title

Ownership %

Date of birth

SSN

Driver's license / ID number

State

Home address, city, state, zip

Home / mobile phone

Phone is text-enabled

Products

Detailed description of products or services offered

Sales profile (should total 100%)

Retail (face to face) %

Internet %

Mail / telephone %

Other %

Customer profile (should total 100%)

Consumer %

Business %

Government %

How will you obtain customer authorization before payments are initiated?Describe in detail — e.g., signed authorization form, website checkbox with terms, recorded phone authorization.

Do you offer time-extended services (subscriptions, memberships, warranties)?

Yes No

Duration of the extended service

Processing history

Anticipated start date

Are you currently processing ACH?

Yes No

Current processor

Reason for leaving

Have you ever been terminated by a processor?

Yes No

Please explain

Anticipated SEC code(s) — select all that apply

ACH debits (collecting payments owed to you)

Monthly transaction count

Monthly amount $

High ticket $

Average ticket $

ACH credits (sending payments you owe) — optional

I need ACH credit origination

By requesting credit origination, you authorize your ACH processing partner to debit your account(s) for all funds initiated for credit origination, and accept full responsibility for all credit originations and fraud prevention. Transactions are not funded to the receiving account until cleared funds are received from your account.

Monthly transaction count

Monthly amount $

High ticket $

Average ticket $

Review your application

On submit, a completed PDF of your application downloads to this device and a copy goes to Merchantic. Merchantic finalizes pricing and sends the full packet for signature. Nothing is sent to the ACH provider until you sign.

Merchant application