Application Cover Sheet

Business DBA Name

Please enter business dba name!

Business Contact First Name

Please enter business contact first name!

Business Contact Last Name

Please enter business contact last name!

Business Address

Please enter business address!

Address Type

Please select an address type!

City

Please enter business city!

State

Please select business state!

Zip Code

Please enter a valid business zip code!

Business Phone #

Please enter a valid business phone number!

Email Address

Please enter a valid email address!

Business Information

Type of Business

Please select a type of business!

Year Established

Please enter a valid year!

Length of Current Ownership

Please enter current ownership year!

year(s),

Please enter current ownership month!

month(s)

Country of Primary Business Operations

Please select country of primary business operations!

Business Country of Formation

Please select business country of formation!

Tax Identification Number (Business)

Please enter business tax identification number!

Is the Legal Name and Legal Address the same as the DBA Name and DBA Address? If No, please add that below

Legal/Corporate Name

Please enter legal/corporate name!

Legal/Corporate Contact Name

Please enter legal/corporate contact name!

Legal/Corporate Address

Please enter legal/corporate address!

City

Please enter legal/corporate city!

State

Please enter legal/corporate state!

Zip Code

Please enter legal/corporate zip code!

Legal/Corporate Phone #

Please enter legal/corporate phone number!

Business Environment - Estimates

Annual Revenue

Please enter annual revenue!

Average Ticket Size

Please enter average ticket size!

What is the highest ticket amount?

Please enter the highest ticket amount!

Descriptions of Products and Services

Please enter descriptions of products and services!

Total Monthly Revenue

Please enter total monthly revenue!

What is the frequency of the highest tickets per year?

Please enter the frequency of the highest tickets per year!

Bank Account

ABA / Routing #

Please enter aba / routing number!

DDA Account #

Please enter dda account number!

Owners and Officers

Please indicate all owners or officers that control greater than or equal to 25% of the business.

Percentage of Ownership

Please enter a valid percentage of ownership!

Principal Title

Please enter principal's title!

First Name

Please enter principal's first name!

Last Name

Please enter principal's last name!

Date of Birth

Year

Month

Day

Please enter a year!

Please enter a month!

Please enter a day!

Country

Please select country!

Residential Address

Please enter principal's residential address!

City

Please enter principal's city!

Zip Code

Please enter principal's zip code!

Address Type

Please select an address type!

Home Phone #

Please enter a valid phone number!

Country of Citizenship

Please select country of citizenship!

ID Type

Please select an id type!

ID Number

Please enter a valid id number!

Percentage of Ownership

Please enter a valid percentage of ownership!

Principal Title

Please enter principal's title!

First Name

Please enter principal's first name!

Last Name

Please enter principal's last name!

Date of Birth

Year

Month

Day

Please enter a year!

Please enter a month!

Please enter a day!

Country

Please select country!

Residential Address

Please enter principal's residential address!

City

Please enter principal's city!

Zip Code

Please enter principal's zip code!

Address Type

Please select an address type!

Home Phone #

Please enter a valid phone number!

Country of Citizenship

Please select country of citizenship!

ID Type

Please select an id type!

ID Number

Please enter a valid id number!

Signing Offices Information

Signing Offices Email Address

Please enter signing offices email address!

Back

Elavon Form

Application Cover Sheet

Business Information

Business Environment - Estimates

Bank Account

Owners and Officers

Owner / Officer #1

Owner / Officer #2 (if required)

Signing Offices Information