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About
Solutions
Team
Contact
Client Information Form
Client Information Form
Please enter the appropriate information in the provided sections below. Click on each section to view entries.Once completed, click
“Submit”
and your information will be sent to Peel Payments and we will be in contact with you regarding next steps.
Business Information
Legal Name
*
First/Last
DBA Name
*
Address
*
Address
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Business Phone
*
Fax Number
Billing Address (if different)
Billing Address (if different)
Billing Address (if different)
Billing Address (if different)
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Federal Tax ID
*
Month/Year Started
*
Annual card Volume ($$$)
Equipment information
Terminal Type (quantity)
Pin Pad Type (if applicable)
IP/WIFI/Analog Phone
Software Type
Vendor/Technician Contact Name
Vendor/Technician Contact E-mail
Vendor/Technician Contact Phone Number
Signor Information
Owner/Officer Legal Name
*
Date of Birth
*
Social Security Number
*
Home Phone
*
Home Address
*
Home Address
Home Address
Home Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
E-mail Address
*
Special Entitlements
Telecheck Number
Micronode (if yes, please provide serial number)
EBT Number
Fuel Man
Banking Information
Routing Number
*
Account Number
*
Bank Name
*
Bank Phone Number
*
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Client Information Form
May 20th, 2016
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