Merchant Apply Now – NextCharge

Merchant Services Application

Name

First Last

Phone

Company name

Business Name DBA

Address (no PO Box):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Federal Tax ID#

Annual Gross Sales (or estimated)

Annual Visa / MC Sales

AVG Ticket / Highest Ticket

Select ONE:

SOLE OWNERSHIP

PARTNERSHIP

NON-PROFIT / TAX EXEMPT CORPORATION

LLC

GOVERNMENT

Date Bus. Began: (M / Y)

Product / SVCS sold:

# of Employees

Website - if available

Signer Name &Title:

Home Phone #

Social Security

Home Address (NO PO BOX)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth (MM/DD/YYYY)

Driver License # / EXP / State

Name of Bank

Routing # (9 digits)

Account #

Terminal / POS / Software

How do you hear about NextCharge?

Working with NextCharge Representative?

Place agent email without '@nextchargesolutions.com'

Name

This field is for validation purposes and should be left unchanged.