Evergreen Payments Northwest General Merchant Account Application - Formstack

Evergreen Payments Northwest General Merchant Account Application Header Image

Business Information

DBA*

Business Location Address*

Address Line 1

City

State/Province

ZIP / Postal

Business Location Phone*

Business Email Address*

Business Website Address*

Date Business Started*

Customer Service Phone*

Customer Service Email Address*

Corporate Name*

Billing Address*

Address Line 1

City

State/Province

ZIP / Postal

Business Contact Name*

First Name

Last Name

Business Contact Email*

Primary Business Contact

Business Contact Phone*

Primary Business Contact

Type of Organization*

Individual / Sole Proprietorship Partnership LLC Corporation - S or C Tax Exempt Organization (501C) Medical or Legal Corporation Association / Estate / Trust Government (Federal, State, Local) International Organization

State or Location Filed*

Federal Tax ID#*

Detailed Explanation of Products Sold*

Business Description*

Fulfillment Center Name

Complete only if you use a fulfillment center to deliver products

Fulfillment Center Contact and Phone

Complete if applicable

Refund Policy

Short Answer - For Example: 30 days, 15 Days, No Refund, Refund or Exchange

Previous Processor (s)

Please provide name(s) of current or previous credit card processor

Owners / Partners / Officers

Please provide this information for each individual who owns, directly or indirectly, 25% or more of the equity interest of your business

Owner / Partner / Officer #1 Name*

First Name

Last Name

% of Ownership*

Owner / Partner / Officer 1

Title*

Owner / Partner / Officer 1

Address*

Address Line 1

City

State/Province

ZIP / Postal

Email - Owner 1*

Owner / Partner / Officer 1

Phone - Owner 1*

Owner / Partner / Officer 1

Social Security Number - Owner 1*

Owner / Partner / Officer 1

DOB *

Owner / Partner / Officer 1

Drivers License Number *

Owner / Partner / Officer 1

Driver Licensing State/Province _ Owner 1*

State/Province

Owner / Partner / Officer #2

Owner / Partner / Officer #2 Name

First Name

Last Name

% of Ownership -Owner 2

Title - Owner 2

Address - Owner 2

Address Line 1

City

State/Province

ZIP / Postal

Email - Owner 2

Phone - Owner 2

Social Security Number - Owner 2

DOB - Owner 2

Drivers License Number - Owner 2

Drivers License State/Province - Owner 2

State/Province

Owner / Partner / Officer #3

Owner / Partner / Officer #3 Name

First Name

Last Name

% of Ownership - Owner 3

Title - Owner 3

Address - Owner 3

Address Line 1

City

State/Province

ZIP / Postal

Email - Owner 3

Phone - Owner 3

Social Security Number - Owner 3

DOB - Owner 3

Drivers License Number - Owner 3

Drivers License State/Province - Owner 3

State/Province

Owner / Partner / Officer #4

Owner / Partner / Officer #4 Name

First Name

Last Name

% of Ownership - Owner 4

Title - Owner 4

Address - Owner 4

Address Line 1

City

State

ZIP Code

Email - Owner 4

Phone - Owner 4

Social Security Number - Owner 4

DOB - Owner 4

Drivers License Number - Owner 4

Drivers License State/Province - Owner 4

State/Province

Settlement Information

Deposit Bank*

ABA / Routing Number or BIC Code*

Checking Account or IBAN Number*

Transaction Information

Requested Monthly Sales Volume*

Monthly American Express Sales Volume

Estimated 20% of Total Expected Credit and Debit Card Sales

Average Sale Amount* $

Average Individual Transaction

High Ticket Amount* $

Think average high sale amount

Where is the Sale Transacted (total must equal 100%)

% of eCommerce Transactions*

% of Keyed / Telephone Order Transactions

% of Swiped / Customer Facing Transactions

If more than 25% Swiped you will need an additional merchant account. We will check in with you about this and will send an additional application for signature if needed.

Required Supporting Documents

Please upload required supporting documents below OR you may email them to us at newaccounts@evergreenpaymentsnorthwest.com. If you have any questions, please call us at 206-339-3556. Otherwise, we will be following up with you regarding your application within 24 business hours.

Articles of Incorporation

No File Chosen

File uploads may not work on some mobile devices.

Articles of Inc, Certificate of Formation, or Business License (Please include all pages). Underwriting will not accept the filing receipt.

EIN Document

No File Chosen

File uploads may not work on some mobile devices.

Screenshots from online dashboard are not acceptable. Acceptable Documents include CP 575 or 147c. If you have lost your EIN Verification Letter from the Department of Treasury, you can request a new one. To do so, call the IRS Business & Specialty Tax Line toll free at 1-800-829-4933 between the hours of 7am and 7pm in your local time zone.

DBA or Fictitious Business Name Registration

No File Chosen

File uploads may not work on some mobile devices.

If Applicable Only. You may have registered a DBA under your Legal Business Name whether you are a sole proprietor, LLC, or Corporation? If so please provide a copy of your registration.

Sales Tax and Use Permit

No File Chosen

File uploads may not work on some mobile devices.

Operating Agreement

No File Chosen

File uploads may not work on some mobile devices.

Applicable only if there are multiple owners. Must be signed and include % of ownership. Please include all pages of document. If you do not have an Operating Agreement we will provide you with a Shareholder Attestation Letter to sign.

Drivers License for Owner / Partner / Officer 1

No File Chosen

File uploads may not work on some mobile devices.

Please provide clear color copy

Drivers License for Owner / Partner / Officer 2

No File Chosen

File uploads may not work on some mobile devices.

clear color copy

Drivers License for Owner / Partner / Officer 3

No File Chosen

File uploads may not work on some mobile devices.

clear color copy

Drivers License for Owner / Partner / Officer 4

No File Chosen

File uploads may not work on some mobile devices.

clear color copy

Voided Check or Bank Verification

No File Chosen

File uploads may not work on some mobile devices.

Business Checking Account Statement 1

No File Chosen

File uploads may not work on some mobile devices.

If Business is New - Please provide Current 3 months of Personal Checking Account Statements

Business Checking Account Statement 2

No File Chosen

File uploads may not work on some mobile devices.

If Business is New - Please provide Current 3 months of Personal Checking Account Statements

Business Checking Account Statement 3

No File Chosen

File uploads may not work on some mobile devices.

If Business is New - Please provide Current 3 months of Personal Checking Account Statements

Merchant Processing Statement 1

No File Chosen

File uploads may not work on some mobile devices.

For Square please provide screenshot of Sales Summary tab showing graph and all information below, separately for each of the current full months.

Merchant Processing Statement 2

No File Chosen

File uploads may not work on some mobile devices.

For Square please provide screenshot of Sales Summary tab showing graph and all information below, separately for each of the current full months.

Merchant Processing Statement 3

No File Chosen

File uploads may not work on some mobile devices.

For Square please provide screenshot of Sales Summary tab showing graph and all information below, separately for each of the current full months.

Fulfillment Agreement if applicable

No File Chosen

File uploads may not work on some mobile devices.

Hemp License or Permit for Growers, Processors, or Food Producers

No File Chosen

File uploads may not work on some mobile devices.

As applicable per State

Laboratory Accreditation

No File Chosen

File uploads may not work on some mobile devices.

As applicable for testing facilities

Lab Reports or Certificate of Analysis

Please email Lab Reports for Hemp derived and/or Kratom products to newaccounts@evergreenpaymentsnorthwest.com with your Business Name in the subject line.

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