Application "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.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 InfoLegal Business Name*DBA Name (if applicable)Years in Business*Referred by (if applicable)Business Physical Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Time at this location*Full Name of Business Contact Person*Business Contact Title*Business Email* Business Phone Number*Business Website*Tax ID*Corp. Type*> Limited Liability Company (LLC)> S Corporation> Corporation> Partnership> Sole ProprietorshipCorp. State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificBusiness Bank*Routing Number*Ownership InfoPrincipal Owner Name*% of Ownership*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Any Additional Owners?* Yes No Principal Owner Name*% of Ownership*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Any Additional Owners?* Yes No Principal Owner Name*% of Ownership*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Any Additional Owners?* Yes No Principal Owner Name*% of Ownership*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Processing InfoHow 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?*Do you have Recurring Payments?* Yes No What % of Monthly Volume is Recurring?*> 1%-10%> 11%-25%> 26%-49%> 50%+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*Do you require website integration?* Yes No What type of website integration do you require?* WooCommerce Shopify Magento Debt Pay Pro Rest API (Used for CRMs, Websites, etc...) Other Select all types of goods or services provided by your business.Animal ServicesAudio/Visual ServicesAuto ServicesBeauty ProductsBilling ServicesBusiness ConsultingBusiness SoftwareCannabis/HempCBDClothing/Apparel Collection AgencyConstructionCredit ConsultingDivorce AssistanceDocument PreperationEducational ServicesEquipment SalesFinancial Consulting Financial ServicesFitnessFood ServicesFurniture SalesGold & SilverHealth/Wellness ServicesIT Services/SoftwareKratomLegal ServicesMarketing ServicesMedical Equip/SupplyMerchant ServicesMoving CompanyOnline EntertainmentOnline ServicesPacking/Shipping SuppliesPeptidesReal Estate/Property ManagementSARMSSEO ConsultingSmoking Accessories Sport ServicesSupplements Tax ServicesTravel ServicesOther Add RemoveDocument UploadTo 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 Select files Max. file size: 50 MB. Bank Document showing business name* Drop files here or Select files Max. file size: 50 MB. Articles of Incorporation Drop files here or Select files Max. file size: 50 MB. Copy of EIN, SS4 or last years tax filling Drop files here or Select files Max. file size: 50 MB. *Additional documents may be requiredEnter an email address where a copy of the form will be sent.* Prove you're not a robot. What is 11+6?*You will be redirected to the terms and conditions signing page after pressing submit. Please read the entire document before signing.
