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BUSINESS APPLICATION

Contact Info | Authorized Company Contact

I am…. *an Officer/Ownersolely a Authorized Contact, no ownership

First Name *

Last Name *

Contact Title

Contact Telephone

Contact Mobile

Contact Email *

Business Vertical *

What Policy Admin system or CRM do you use?

Insurance Entity Type

Product(s)

What States are you licensed in?

Other Type

Business Information

Company Legal Name *

Business Name DBA (Doing Business As) *

Business License *

No file chosen

Company Website

Business Start Date *

Business Type *Sole PropretorPartnershipPublic Corp.LLC/LLPPrivate CorpNon-ProfitGovernment

State Filed *

Location Business Address (No P.O. Box Accepted)

Street Address *

City *

ZIP / Postal Code *

State/Region/Province *

Country *

Same as location address

Federal Tax ID / EIN *

Business Telephone *

Fax

Number of Locations *

Customer Service Telephone *

Customer Service Email *

Processing Volume | If not yet coll. payments, please estimate expected volume six months from now.

CC Average Ticket USD *

USD

CC High Ticket Amount USD *

USD

CC Monthly Volume USD *

USD

ACH Average Ticket USD *

USD

ACH High Ticket Amount USD *

USD

ACH Monthly Volume USD *

USD

Recent Processing Statements

No file chosen

If you are currently processing, please provide three months most recent processing statements.

How did you hear about us?

Owner/Officers #1

First Name *

Last Name *

Owner ID *

No file chosen

Owner Official Government Identification

Job Title *

Street Address *

City *

ZIP / Postal Code

State *

Home Telephone *

Drivers Licence Number *

Social Security Number *

Date of Birth *

Equity/ Ownership % *

Owner #1 Email Address *

Is the company owned by a parent company? *YesNo

Parent Company Details

Parent Company Name *

Business Phone *

Business Contact Email *

Business Tax ID / EIN *

Business Address *

Business City *

Business State *

Business Zip Code *

Business Equity / Ownership % *

Do you need to list additional Owners? *YesNo

Owner/Officers #2

First Name *

Last Name *

Owner ID *

No file chosen

Owner Official Government Identification

Job Title *

Street Address *

City *

ZIP / Postal Code

State *

Home Telephone *

Drivers Licence Number *

Social Security Number *

Date of Birth *

Equity/ Ownership % *

Owner #2 Email Address *

Do you need to list additional Owners? *YesNo

Owner/Officers #3

First Name *

Last Name *

Owner ID *

No file chosen

Owner Official Government Identification

Job Title *

Street Address *

City *

ZIP / Postal Code

State *

Home Telephone *

Drivers Licence Number *

Social Security Number *

Date of Birth *

Equity/ Ownership % *

Owner #3 Email Address *

Do you need to list additional Owners? *YesNo

Owner/Officers #4

First Name *

Last Name *

Owner ID *

No file chosen

Owner Official Government Identification

Job Title *

Street Address *

City *

ZIP / Postal Code

State *

Home Telephone *

Drivers Licence Number *

Social Security Number *

Date of Birth *

Equity/ Ownership % *

Owner #4 Email Address *

Do you need to list additional Owners? *YesNo

Owner/Officers #5

First Name *

Last Name *

Owner ID *

No file chosen

Owner Official Government Identification

Job Title *

Street Address *

City *

ZIP / Postal Code

State *

Home Telephone *

Drivers Licence Number *

Social Security Number *

Date of Birth *

Equity/ Ownership % *

Owner #5 Email Address *

Do you need to list additional Owners? *YesNo

Owner/Officers #6

First Name *

Last Name *

Owner ID *

No file chosen

Owner Official Government Identification

Job Title *

Street Address *

City *

ZIP / Postal Code

State *

Home Telephone *

Drivers Licence Number *

Social Security Number *

Date of Birth *

Equity/ Ownership % *

Owner #6 Email Address *

Bank Account Information

Bank Name *

Routing Number # *

Bank Account # *

Account Type *CheckingSavings

Void Check *

Drag and Drop (or) Choose Files

Account Services

Processing Fees: *Assume all processing feesPass on processing fees to my end customer

Terminal Type *VirtualPhysical

How many? *

Services *Credit CardACH

ACH Authorization Form *

No file chosen

Information Review

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Accuracy is essential for a smooth and swift application process.

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Contact
info@clidpay.us
760 712 6725
1508 N Main St, Santa Ana, CA 92701
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