Trifinity Card Processing Information Request
All Boxes Must Be Filled. If not applicable put NA
Business Name:________________________ Company Phone Number: _____________
Business Owner’s Name: _______________________________________ Ownership _____%
Business Owner’s Name: _______________________________________ Ownership _____%
Business Owner’s Name: _______________________________________ Ownership _____%
Primary Owner’s Address: ____________________________ _______ / ______ / _________
Street Address PO Box State Zip Code
(If Any)
Contact: Name:__________________ Title: _____ Email:______________ Cell:___________
Legal Name of Business: ___________________________ Bus Type-____(LLC, Corp, Sole Proprietor)
Business Location: _____________________________________ _____ / ______ / ________
Street Address PO Box State Zip Code
(If Any)
Business Website:_________________________ Fed Tax ID: _________ Years In Bus: ____,
Date Began: ____ Primary Owner’s Social Security Number: ___________ Date of Birth: ____
Average Monthly Sales: $ _______ Percentage Cards: __% Percentage Cash or Checks ___%
Card Sales Ticket Size: Low $ ___ Average $____ High $____ Monthly Card Sales: $_______
Current Processor: __________________ Process you use? (Smart Phone/Wi-Fi/Plug In): _______
Bank Name: ____________________ Bank Routing #: ____________ Account #: __________
Products/Services: _____________________________________________________________
Note: _______________________________________________________________________,
Agency Underwriting is to contact the Business Owner/Contact:_______ Date ____ Time:____
Owner Name Print: ________________Signature: ________________________ Date: ______
(The Agent certifies that they (Have or Have Not) (_________) inspected the above Business)
Agent Name: _________________ Agent #: _____Signature: _________________ Date: ____
Agent’s Phone Number: ________________ Agents Email Address:_____________________