Country of Primary Business Operations *

Entity *

Channel

Bank Branch Number

Primary Sales Rep Override

Contact First Name

Contact Last Name

Address (line 1) *

Address (line 2)

Zip *

City *

State *

Legal Address *

Address Classification

Address (line 1)

Address (line 2)

Zip/Postal Code *

City *

State/Province *

Country *

Mailing Address

Shipping Address

Legal Verification *

Evidence of Legal Status:

Evidence of Legal Status *

Principal Information

Name and Residential Address:

First Name *

Middle Initial/Name *

Last Name *

Residential Address *

Address Classification *

Address (line 1) *

Address (line 2)

Zip/Postal Code *

City *

State/Province *

Country *

*

At Address less than 2 years

Identification and Ownership:

Responsible Party *

Ownership % *

%

Principal Title *

Date of Birth *

Principal will be signing a Personal Guarantee *

ID Type *

Contact Information:

We are requesting your mobile phone number and e-mail address to help us service your account.

Phone *

Email *

Residency: If the Principal has citizenship in more than two countries and one is the United States, please ensure to select United States for Country of Citizenship 1 or Country of Citizenship 2.

Country of Citizenship 1 *

Country of Citizenship 2 *

The customer has confirmed that there are no further principals with 25% or greater interest in the business. *

Statements:

Statement Delivery Method *

Statement Delivery Address

Chargeback Delivery Method *

Retrieval Delivery Method *

Pricing

Card Acceptance

All Cards

American Express

Discover (JCB, Diners, PayPal)

MasterCard Credit

MasterCard Debit

Union Pay Credit

Visa Credit

Visa Debit

Price each card individually

Pricing Method *

Pricing Category *

Billing Method *

EFT Debit Cards

PIN Debit

PINLess Debit

Authorizations Included *

Minimum Monthly Fee*

Quantity *

Amount *

$

Voice Authorization with AVS*

Amount *

$

Voice Operator Assisted *

$

Voice Referral *

$

Voice Auth Touchtone Fee *

$

Chargeback Fee *

$

NSF Fee *

2

Point Of Sale

You must select an MCC (Section 1) and Card Acceptance Split (Section 5) to add Equipment.

Do you want to see Pilot Equipment? *

Equipment Supplier *

No Equipment Required

Bank Account

Deposit Account

ABA Routing # *

Account Number *

Billing Account

Chargeback Account

Daily Discount

Funding:

Funding Type *

Notes and Documents

Attachments

Per Elavon policy do not upload copies of any personal identification document including but not limited to U.S. State Driver’s License, U.S. Government issued Military ID, Foreign-issued Photo ID, Foreign-issued Visa, Mexican Matricula Card, Social Security Card, U.S. Alien Resident Immigrant ID, U.S. Passport, U.S. State ID.

The Note section is only to provide additional information to the credit underwriting team.

Notes

Chain Information

Is this application part of a chain? *

Create Account

Validate Principal's Email Address *

advanced form

Customer Information

Addresses

Business Address

Principal Information

Contact Information:

Statements:

Financial Information

Revenue:

Transactions:

Card Acceptance (per channel):

Pricing

Point Of Sale

Bank Account

Funding:

Notes and Documents

Chain Information

Create Account

Contact Form