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Desormais Management Application Form

Agents Application - Desormais Management

Basic Contact Information
Name
Hidden
Referral Partner*
Hidden
Lead Source*
Email
Company
Phone
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Legal Business Information
Legal Business Name
Business Incorporation Type (LLC, S Corp, Corp, etc..)
Federal Tax ID
Age of the Business
Average Ticket Amount
Average Monthly Volume
Legal Business Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is Your Business Doing-Business-As Another Name?
- Yes
- No
Doing-Business-As Name
Doing-Business-As Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Website
Description of Business Services
Payment Information
Upload Scanned Image of a Blank Check
Max. file size: 64 MB.
Bank Name
Bank Routing Number
Bank Account Number
Daily Batch Settlement Time

: Hours

Minutes
Funding Options
- Next Day
- 2 Day Funding
Account Guarantor Information
Legal Owner Name
Job Title
Ownership Percentage
Personal Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Social Security
Scanned Image of Government Issued ID
Drop files here or

Max. file size: 64 MB.
Account Guarantor Information
Legal Owner Name
Job Title
Ownership Percentage
Personal Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Social Security
Scanned Image of Government Issued ID
Drop files here or

Max. file size: 64 MB.
Technologies
Desired Method(s) of Accepting Payments
- Phone Line Terminal
- Internet Connected Terminal
- Wireless Terminal
- Virtual Terminal
- Ecommerce
- Mobile Phone Swiper
- Point of Sale
Terminal Information
Additional Information
Processing Pricing
Visa/MasterCard/Discover/AMEX Rate (Basis Points)
Transaction Discount Rate
Gateway Fee (if applicable)
Batch Settlement Fee
Monthly Statement Fee
Monthly Minimum Processing
Annual IRS Mandate Compliance
Monthly Gateway Fee
PCI Compliance Fee
POS Pricing
POS Setup Fee (If Applicable)
POS Monthly Fee (If applicable)

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