New or Existing Customer

• I am a new customer
• I am an existing customer

Name *

First

Last

Business Legal Name (include LLC, Inc. etc.) *

Federal Tax ID *

Date Company Started *

DBA Name ( Doing business as ) *

Business Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Business Phone Number *

Latest time of the day your business closes *

Business Type (what is being sold)?

• Retail/Store Card Present
• Grocery/Convenience Store
• Liquor Store
• Tobacco Shop
• Restaurant
• Deli/Quick Serve Restaurant
• Online B2C
• Online B2B
• Online Hemp/Delta
• Hemp based products store
• Hair/Nail Salon
• Other

Average Ticket Amount (average total customers spend on 1 visit) *

Average Monthly Credit Card Sales *

Email *

Owner SSN *

Owner Cell Phone

State Tax ID – NRS POS ORDERS ONLY

Voided Check or Bank Letter (jpg, pdf, png, gif)

Drivers License (jpg, pdf, png, gif)

EIN Letter (from IRS) – NRS POS ORDERS ONLY (jpg, pdf, png, gif)

Please Check any Services That May Apply

• Credit Card Processing
• Credit Card Processing Zero Rate (Cash DIscount Program)
• NRS POS w/ Card Processing
• Point of Sale – Information Needed

Preferred contact method

• Call
• Text
• Email

Maverick Person You are Working With?

First

Last

Additional Comments – Let us know any additional info or questions you have below

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