Payments Questionnaire

Legal Business Information

Business Legal Name(Required)

Business DBA

Business Entity(Required)

Business Legal Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Phone(Required)

Email(Required)

Business Start Date(Required)

Business Website(Required)

Federal EIN(Required)

Do you need funding for growth, inventory, payroll, or other daily business needs?

We have access to a fund specifically setup to fund businesses that need capital. Funding approval requires 2+ years in business with the ability to show incoming revenue.

Owner or Account Signer Personal Information

Individuals with equity ownership of 25% or more must be disclosed.

Owner Name(Required)

First Last

Title(Required)

Owner Email Address(Required)

Enter Email Confirm Email

Owner Phone(Required)

Owner Personal Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Ownership Percentage(Required)

Date of Birth(Required)

Social Security Number(Required)

Drivers License Number(Required)

Drivers License Issue Date(Required)

Drivers License Expiration Date(Required)

Drivers License State(Required)

Best Time To Call You(Required)

When is the best time for us to reach you via telephone?

Payment Processing Information

Annual Sales Volume(Required)

Average Transaction Amount(Required)

Largest Expected One Time Transaction(Required)

Explain Largest Transaction Amount in Detail

Do you prefer fees to be taken out daily or monthly? (please check one)(Required)

Daily Discount (fees taken out daily)

Monthly Discount (fees taken out monthly

Banking Information

Bank Name(Required)

Routing Number(Required)

Bank Account Number(Required)

Your Business Services

Percentage of business to business transactions (please estimate out of 100%)(Required)

Percentage of business to consumer transactions (please estimate out of 100%)(Required)

Percentage of transactions that take place online (please estimate out of 100%)(Required)

Percentage of transactions that take place over the phone (please estimate out of 100%)(Required)

Percentage of transactions that take place in person (please estimate out of 100%)(Required)

Where is your business located? Please select one.(Required)

If you work out of an office building, industrial building, or shopping center, do you rent or own?

If you work out of an office building, industrial building, or shopping center, what is the approximate square footage?

Do you have a refund policy? If yes, please add link below(Required)

Yes

No

Link to refund policy

Do you offer subscriptions (auto-bill)?(Required)

Yes

No

More About You

Is there anything else we need to know about your business?

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Akord Payments Application Questionnaire