Synergy Pay Solutions

Thanks for your interest in eDebit Direct. Please fill in your company information and we can typically have you up and running in as little as 24 hours!

Business Info

Legal Business Name*

DBA Name (if applicable)

Years in Business*

Referred by (if applicable)

Time at this location*

Full Name of Business Contact Person*

Business Contact Title*

Business Email*

Business Phone Number*

Business Website*

Tax ID*

Corp. Type*

Corp. State*

Business Bank*

Routing Number*

Ownership Info

Principal Owner Name*

% of Ownership*

Email*

Phone*

Principal Owner Name*

% of Ownership*

Email*

Phone*

Principal Owner Name*

% of Ownership*

Email*

Phone*

Principal Owner Name*

% of Ownership*

Email*

Phone*

Processing Info

How many transactions (debits) will you process per month?*

What is the average dollar amount per transaction?*

Highest amount you receive on any single transaction*

Estimated monthly dollar amount of transactions?*

What % of Monthly Volume is Recurring?*

What is your refund policy?*

What is the average dollar amount per refund?*

What is your estimated monthly dollars refunded?*

Describe how you market your goods or services*

Document Upload

To expedite your account approval please upload all 4 of the following documents. They will be placed in a secure/encrypted DropBox.

Copy of Owners Driver’s License or Passport*

Drop files here or

Max. file size: 50 MB.

Bank Document showing business name*

Drop files here or

Max. file size: 50 MB.

Articles of Incorporation

Drop files here or

Max. file size: 50 MB.

Copy of EIN, SS4 or last years tax filling

Drop files here or

Max. file size: 50 MB.

*Additional documents may be required

Enter an email address where a copy of the form will be sent.*

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Phone

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