<%@ Language=VBScript %> Test

CHEXpedite
Online Electronic Check
Application Merchant Application

Basic Business Information

Merchant’s Legal Name:  
DBA:  
Physical Address:  
City:    State:  Zip: 
Mailing Address:  
City:    State:  Zip: 
Phone:    Ext.   Fax:  
Company e-mail:  
Customer Service Phone #:      Number of years in business: 
Contact Name:    Title: 
Contact e-mail:  
Federal ID #:    State ID #: 
Sales Tax #:  

Type of Business (Check one)
Collections Mail Order Telemarketing Inbound Outbound
Catalog Audio Text Internet
Other *(Please give a very detailed description of business).

Banking References
Method of Payment: ACH
Primary Bank:   Name as on Account:  
Bank Officer:  Bank Phone (including area code):  
Bank RTN:   Account Number:  
                                                                                              

Personal Data, Owner / President
Name: Home Phone:
Title: SSN:
Home Address:
City:          State:  Zip: 
 
Name: Home Phone:
Title: SSN:
Home Address:
City:          State:  Zip: 
To induce NBDS, Inc. (National Bank Drafting Systems, Inc.) reliance thereon, the undersigned certifies the accuracy of all the foregoing information and authorizes Bank or Credit Bureau or other investigative agency employed by NBDS, Inc. to investigate the reference given to NBDS, Inc.or statements or other data contained herein obtained from Merchant or from other persons pertaining to Merchant’s credit, financial responsibility or accuracy of any of the foregoing information. The person signing this agreement certifies that he/she is authorized to enter into this agreement on behalf of client. I/We further agree to notify NBDS, Inc. of any and all changes which may occur from time to time in the information and statements contained herein.:

Name of Authorized Signer on account:  
    Title:     

Please review all information before clicking 'Print Form'

 

Total Payment Solutions, Inc.                           Licensee #: A3908