Person Completing This Application

    First Name*

    Last Name*

    Title (Position with company)*

    Email*

    Work Phone*

    Fax

    Mobile Phone

    How did you hear about Amerifirst?*

    Select which sales manager introduced you to AmeriFirst

    Select which referral partner introduced you to AmeriFirst

    Are you an owner?*
    YesNo


    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.