Language
English (US)
MERCHANT APPLICATION
CORPORATE/LEGAL INFORMATION
Legal Name
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Main Contact Email Address
example@example.com
Corporate Phone Number
DBA (If different from legal name)
Federal Tax ID
*
Length of Ownership
Business Start Date
/
Month
/
Day
Year
Date
Website
Type of Business (select all that apply):
Cannabis
Non‐Cannabis/Ancillary
CBD
Cultivation
Retail
Manufacturer
Testing/Distributor
Other
RETAIL LOCATION(S) INFORMATION
RETAIL LOCATION #1
Lease or Own
Please Select
Lease
Own
Landlord Name
Telephone
Merchant Location
Shopping Center
Retail Storefront
Residence Mobile
Other
Area Zoned
Commercial
Residential
Industrial
Years at Location
Location Address
City
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Location Main Phone Number
Fax Number
RETAIL LOCATION #2
SELECT ONE
LEASE
OWN
Other
Landlord Name
Telephone
Merchant Location
Shopping Center
Retail Storefront
Residence Mobile Merchant
Office Building
Area Zoned
Commercial
Residential
Industrial
Years at Location
Location Address
City
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Location Main Phone Number
Fax Number
RETAIL LOCATION #3
SELECT ONE
Lease
Own
Other
Landlord Name
Telephone
Merchant Location
Shopping Center
Retail Storefront
Residence Mobile
Office Building
Area Zoned
Commercial
Residential
Industrial
Years at Location
Location Address
City
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Location Main Phone Number
Fax Number
OWNERSHIP INFORMATION
OWNERSHIP PERCENTAGE
Contact Email Address
example@example.com
Name of Owner
Title
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Social Security
Equity Ownership
Date of Birth
/
Month
/
Day
Year
Date
Phone Number
Driver’s License
Driver's License State
Please Select
If the owner does not hold 51% equity please provide additional ownership information below
Title
OWNERSHIP PERCENTAGE
Contact Email Address
example@example.com
Name of Owner
Home Address
City
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Social Security
Equity Ownership
Date of Birth
/
Month
/
Day
Year
Date
Phone Number
Driver’s License
Driver's License State
Please Select
BANKING INFORMATION
Name of Bank
Name of Bank Manager
Account Number
Routing Number
Address
Address
City
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Companies bank has a verified cannabis program
Yes
No
Name of company providing cash transport
SALES ACTIVITY
Maximum Single Debit Item
Maximum Single Credit Item
Maximum Single Debit Item
Maximum Single Credit Item
Average Gross Sales for last 3 months
Expected Gross Income this year
Gross Income last year
BUSINESS TRANSACTION ACTIVITY
Average Gross Sales for last 3 months
Expected Gross income this year
Gross Income last year
SUPPORTING DOCUMENTS
EIN LETTER - Taxpayer Identification and/or employer ID
*
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OPERATING AGREEMENT
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BYLAWS, MINUTES AND/OR RESOLUTIONS AUTHORIZING WHO MAY OPEN AND SIGN ON ACCOUNTS
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LICENSE(S) TO DO BUSINESS (Business registrations / Tax Licenses)
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ARTICLES OF ORGANIZATION
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MOST RECENT 2 YEARS OF COMPNAY FINANCIAL STATEMENTS
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THREE MOST RECENT CONSECUTIVE COMPANY BANK ACCOUNT STATMENTS
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COPY OF OWNER(S) DRIVERS LICENSE
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COPY OF PRE-PRINTED VOIDED CHECK WITH COMPANY NAME/ADDRESS
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NOTICE AND EXPLANATION OF ANY LEGAL ISSUES RELATED TO COMPANY
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