Payhawk Merchant Profile Form - COPY

Corporate/ Legal Name*

Must match W-9/ business tax information

Doing Business As/ Public Business Name

Web Site*

If your business does not have a website, put "N/A"

Brief Description of Products/Services*

Company Contact/Authorized Signer*

First Name

Last Name

Company Contact/Authorized Signer Email*

Who is your Sales Representative?*

Please select from the list your point of contact with GoPayhawk

Business Type*

Public Corp Closely Held Corp Sub S Corp LLC Partnership Sole Proprietorship Non-Profit

LLC Type

Date Started*

Federal Tax ID#*

Physical Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Legal Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Business Phone*

Another location?*

Yes No

Fax Number

Business Email*

State of Incorporation*

Est. Monthly Visa/MasterCard Volume* $

Est. Average Transaction Amount* $

Maximum Ticket Amount*

% of Card Present Transactions*

Roughly what amount of business is a physical card run through a terminal?

% of Internet/E-Commerce Transactions*

Roughly what amount of business is done through the internet?

% of Card Not Present Transactions*

Roughly what amount of business is manual entry of card data?

Owner / Proprietor (Account signer)*

First Name

Last Name

Ownership Percentage*

Home Address of Owner / Proprietor*

Address Line 1

Address Line 2

City

State

ZIP Code

Owner/Proprietor Email*

Mobile Phone*

Social Security # of Owner / Proprietor*

Birth Date of Owner / Proprietor*

Owner / Proprietor - 2

First Name

Last Name

Ownership Percentage

Home Address of Owner/Proprietor 2

Address Line 1

Address Line 2

City

State

ZIP Code

Mobile Phone

Social Security # of Owner / Proprietor - 2

Birth Date of Owner / Proprietor - 2

Name of Bank to Deposit Funds*

Deposit Account Number*

Deposit Routing Number*

Name of Bank to Bill Funds

If different than Deposit Bank

Billing Account Number

If different from Deposit Account Number

Billing Routing Number

If different from Deposit Routing Number

How would you like to receive your monthly statements? (Check one)

Electronic Mail (Business Address) Mail (Home Address)