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Contact / DBA Details
First Name*
Last Name*
Email*
Phone*
Company*
Cashless ATM Payments Signup Details
Payment Types Interest* (select at least one)
Debit
ACH
Wallet
Website URL
Corporate Info
Corporate Name*
Position in Company*
DBA (Doing Business as)
Corporate Address*
Corporate Phone*
Corporate Email Address*
E.I.N. / Tax ID #*
Location Info
Location Name*
Location Address*
Location Phone*
Location Email
Location Contact
Average Debit Ticket
Monthly Debit Volume
Location Time Zone
# of Retail Only Terminals Needed
# of Delivery Terminals Needed
Officer Info
Name
Address
Date of Birth
Phone
Email
About Your Company
Monthly Sales*
Percentage of Sales in Cash
Currently Using Payment Processing?*
Yes
No
Payment Processor
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Protopay
Greenlink
Merchant Club
BankCard International
IPP
Other
Account Handler
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What type of sales does your company do?*
Physical retail storefront
E-commerce
Delivery
B2B Wholesale
Other
What are your current payment methods?*
Cash
Debit
Credit Card
ACH
Cashless ATM
Other
Owner's Drivers License or State ID
Cannabis License
Articles of Inc or Business License
Most Recent Bank Statement
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How did you hear about us?
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I Heart Jane
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