Merchant Form

Business Information

Legal Name Of Business

DBA Name

Date Of Business Established

Taxpayer identyfication number

Business Phone No

Type Of Business

Business Email

Business Website

Physical Address

Unit

State

City

Zip Code

Billing Address

Unit

State

City

Zip Code

Principal Information

List Name One Principal owner position help with company

Last Name

First Name

Middle Name

Title

Ownership Percentage

Date Of Birth

Social Security Number

Home Phone

Cell Phone Number

Your Address

Unit

State

City

Zip Code

Driving Lincense Number

Lincense Expiry Date

Owner Email Address

Attachment Required

Driver Licenses

Voided Check or Bank Letter

Banking Information

Name Of the Bank

Bank Address

Business Checking Account Number

Business Checking Routing Number

Acceptance

I Accept the Terms and Conditions

Patel Processing, LLC is a registered ISO of Wells Fargo Bank, N.A., Concord, CA

Business Information

Principal Information

List Name One Principal owner position help with company

Attachment Required

Banking Information

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