Remedy Payment Solutions

Legal Business Name*
Doing Business As Name (DBA)*
Business Phone Number*
Business Email Address
Business Website*
Business Management Software Provider
Business Location Address*
Street Address City State ZIP Code
Is the Business Location Address the same as the Legal Business Address?*
- Yes
- No
Preferred Address for Mail and Chargeback Correspondence*
- DBA Address
- Legal Address
Address (Legal Address)*
Street (Legal Address) City State ZIP Code
Merchant Location*
Business Entity Structure*
Federal Tax ID Number*
Business Start Date (Estimated)*
Describe Products and/or Services Sold*

Business Owner’s Information:
Name
First Last
Home Address*
Street Address City State ZIP Code
Cell Phone Number*
Ownership Percentage*
Owners SSN*

Note: As a financial institution, we are required per the Patriot Act to verify the identity of any individual or corporation opening a new merchant account. A Valid SSN is required.
Owners DOB*