Life Flavors

Application

"*" indicates required fields

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)

Business Physical Address*

Street Address Address Line 2 City 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*

Corp. State*

Business Bank*

Routing Number*

Ownership Info

Principal Owner Name*

% of Ownership*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Any Additional Owners?*

Yes

Principal Owner Name*

% of Ownership*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Any Additional Owners?*

Yes

Principal Owner Name*

% of Ownership*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Any Additional Owners?*

Yes

Principal Owner Name*

% of Ownership*

Address*

Street Address Address Line 2 City State ZIP Code

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?*

Do you have Recurring Payments?*

Yes

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*

Do you require website integration?*

Yes

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.