Payment Processing Form

MERCHANT PROCESSING FORM

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account or loan. When you (the customer) open an account or loan, we will ask for your name, address, date of birth (for natural persons), tax identification or social security number and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.

BUSINESS INFORMATION

K5 Representative(Required)

FULL NAME OF OWNER(Required)

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FIRST NAME

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LAST NAME

STREET ADDRESS(Required)

CITY(Required)

STATE(Required)

ZIP(Required)

BUSINESS PHONE(Required)

EMAIL ADDRESS(Required)

DATE OF BIRTH(Required)

SSN(Required)

BUSINESS NAME (DBA)(Required)

LOCATION STREET ADDRESS

DATE BUSINESS STARTED(Required)

TAX ID NUMBER (EIN)(Required)

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Owner (Static and Hidden)

ENTITY TYPE(Required)

INDUSTRY(Required)

PRODUCTS/SERVICES SOLD(Required)

Past 3 Months Payment Processing Statements

Drop files here or

Max. file size: 512 MB.

Drivers License

Max. file size: 512 MB.

Copy of Void Check

Max. file size: 512 MB.

Signature(Required)

Payment Processing Form

MERCHANT PROCESSING FORM

BUSINESS INFORMATION

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