Merchant Application Form- AmeriFirst

Person Completing This Application

Name

First Name*

Last Name*

Title (Position with company)*

Email*

Work Phone*

Fax

Mobile Phone

How did you hear about Amerifirst?*

Are you an owner?*
YesNo

Other

Business Information

Business Category*

Business Legal Name (Merchant)*

Federal Tax ID# or Social Security Number
Federal Tax IDSocial Security Number

Federal Tax ID#
-

Social Security Number
- -

All Names you are Doing Business As*

In Business Since*

Business Structure*

Website/Business URL

Annual Sales Revenue ($)*

Annual Finance Volume ($)*

Average Sale Price*

Products Sold (hold ctrl on Windows or command on Mac to select multiple)*

National or Enterprise Account Affiliation (if any)

Physical Address

Street Address*

Address line 2

City*

State*

Zip Code*

Mailing Address

Same as Physical Address

Street Address

Address line 2

City

State

Zip Code

Principal, Partner or Owner Information

Please list all who have ownership interest of 25% or more

Name

First Name*

Last Name*

Email*

Mobile Phone

Birthdate*

Owner Since

Social Security #*
- -

Ownership Percentage*

Home Address

Street Address*

Address line 2

City*

State*

Zip Code*

Add another Principal, Partner or Owner

Additional Principal, Partner or Owner Information

Name

First Name

Last Name

Email

Mobile Phone

Birthdate

Owner Since

Social Security #
- -

Ownership Percentage

Home Address

Street Address

Address line 2

City

State

Zip Code

Add another Principal, Partner or Owner

Additional Principal, Partner or Owner Information

Name

First Name

Last Name

Email

Mobile Phone

Birthdate

Owner Since

Social Security #
- -

Ownership Percentage

Home Address

Street Address

Address line 2

City

State

Zip Code

Add another Principal, Partner or Owner

Additional Principal, Partner or Owner Information

Name

First Name

Last Name

Email

Mobile Phone

Birthdate

Owner Since

Social Security #
- -

Ownership Percentage

Home Address

Street Address

Address line 2

City

State

Zip Code

By Clicking the check box below and submitting this application, you are certifying that you have read and agree to all Disclosures and the Merchant Financing Agreement.

Sole Proprietorships and Partnerships: AmeriFirst may check and verify the credit history and secure credit reports for the Applicant(s) and any named or disclosed principals, owners or partners. The named or disclosed principals, owners or partners instruct and authorize any third party including but not limited to any consumer reporting agency, partner, subsidiary, and vendor to provide such report.

Corporations: AmeriFirst may check and verify the credit history and secure credit report for the Applicant and any named or disclosed shareholders, stockholders, principals or owners. The named or disclosed shareholders, stockholders, principals or owners instruct and authorize any third party including but not limited to any consumer reporting agency, partner, subsidiary, and vendor to provide such report.

I certify that the information submitted is true, accurate and complete. By submitting this Application, I certify that I have read and agree to the complete Disclosures and Merchant Financing Agreement.