ACH Merchant Agreement
Fees and Charges
ACH
0.75%
Merchant Information
EIN
____________________________________________________________________
Nine-digit number assigned by the Internal Revenue Service (IRS) for the purposes of identification.
Organization Legal
Name
____________________________________________________________________
This should match the name of your organization given for your EIN application
Merchant Name
____________________________________________________________________
This name will be displayed to your customers on their bank or credit card statement
Physical Address of
Organization
____________________________________________________________________
PO boxes are not allowed
City, State, Zip
____________________________________________________________________
Business Phone
Number
____________________________________________________________________
This number will be displayed to your customers on their bank or credit card statement
Billing Contact Name
____________________________________________________________________
Billing Email Address
____________________________________________________________________
Contact Mobile
Number
____________________________________________________________________
Used for two-factor authentication to login to payment processor website
Bank Information
Bank Name
____________________________________________________________________
Bank Routing Number
____________________________________________________________________
Bank Account
____________________________________________________________________
Controlling Officer Information
The undersigned Controlling Officer (hereinafter “Signator”) represent that all information contained in this Beneficial Ownership
Disclosure (“Disclosure”) is true and correct. Signator hereby acknowledges that in order to fight the funding of terrorism and money
laundering activities, and to comply with FinCEN beneficial owner requirements, CircuiTree, LLC and its agents (“CircuiTree”) are
required to verify the identity of the controlling officer of Merchant. Therefore, the undersigned agrees that CircuiTree are authorized to
obtain consumer and (if applicable) business credit reports and to undertake a criminal background investigation of Merchant and
Signator in connection with this Disclosure. Signator authorizes CircuiTree to investigate information or data obtained from this
Disclosure and agree to provide any further information, including financial data, as may be reasonably requested by CircuiTree.
Signator may, upon written request, obtain a complete and accurate disclosure of the nature and scope of the investigation requested
hereunder with respect to their individual information submitted. This Disclosure may be executed by using an electronic or handwritten
signature, which are of equal effect, whether on original or electronic copies. The data supplied will be used only for account validation
purposes and will not be sold or distributed to third parties. The controlling officer is an owner, employee or volunteer authorized to
conduct business and enter into contracts on behalf of the merchant. For non-profit organizations, you will be required to list a volunteer
or administrator with significant decision-making power.
By signing below, Signator also agrees to the terms and conditions detailed in
https://circuitree.com/creditcardprocessingagreement
Controlling Officer
____________________________________________________________________
Title
____________________________________________________________________
Residential Address
____________________________________________________________________
City, State, Zip
____________________________________________________________________
Phone Number
____________________________________________________________________
SSN
___________________________ Date of Birth ___________________________
The data supplied will be used only for account validation purposes and will not be sold or distributed to third parties
Signature X ____________________________________________ Date ___________________
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