Simple Fee Program

Support: 844-244-1757 merchantsales@pathward.com

Simple Fee Program Application

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Number of Beneficiary Owners

Owner

Title

Percent Ownership (numbers only)

First Name

Last Name

SSN

Date of Birth (mm-dd-yyyy)

U.S. Citizen

Yes

Country

Street Address (No Virtual Office Address)

City

State

Zip Code

Business Information

Business Legal Name

Doing Business As

EIN/SSN

Merchant Category Code

Type of Business

Business Description

Business Phone Number

Day Phone

Evening Phone

Monthly Bank Card Volume

Average Ticket

Highest Ticket

Street Address (No Virtual Office Address)

Address2

City

State

Zip Code

Username

Password

Website URL

Notifications Email

Bank Information

Bank Name

Account Name

Account Ownership Type

Business Description

Type of Account

Routing Number

Bank Account Number

Tier

COM_MERCHANT_FORM_LBL_COMPANY_CARD_PRESENT

COM_MERCHANT_FORM_LBL_COMPANY_CARD_PRESENT_KEYED

COM_MERCHANT_FORM_LBL_COMPANY_CARD_PRESENT_ECOMMERCE

Currency Type

Same As Personal Information

Service Acknowledgment

I acknowledge that:

By Clicking the "Agree" button below, I acknowledge that am enrolling in merchant services offered by Pathward, NA and powered by ProPay.
By Clicking the "Agree" button below, I acknowledge that I have read and understood the sub-merchant Terms & Conditions located online at Terms and Conditions.
Electronic Communication Policy located online at Electronic Communication Agreement.
By Clicking the "Agree" button below, I attest that there are no other individuals that have 25% ownership or a controlling interest in the company that has not already been disclosed elsewhere in the application process.
I agree that this eletronic agreement has the same full legal force and effect as a handwritten signature or mark.

Yes

Terms Acceptance Timestamp

IP Address Terms Accepted From *

Terms Version

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