Merchant Processing FormDBA Name*Legal Name*Contact Name* First Last Contact Title*Business Phone*WebsiteDBA Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Is the legal address the same as the DBA address?* No Yes Legal Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Application Language* English French Salesforce Opportunity Link* Base RatesDebit $*Interchange Surcharge %*Card Brand Fee % (if applicable)One-Time Application Fee $*Annual Fee $*Monthly Fee $*PCI Quarterly Fees (Nuvei) $Visa/MasterCard Authorization Fee/Per Item $*Visa/MasterCard Minimum Monthly Fee $*Personal Information% of Ownership (owner #1)*% of Ownership (owner #2)Owner #1 Name* First Last Owner #2 Name First Last Owner #1 Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Owner #2 Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Owner #1 Email* Owner #2 Email Owner #1 Phone*Owner #2 PhoneOwner #1 Date of Birth*Owner #2 Date of BirthOwner #1 ID Drop files here or Select files Accepted file types: jpg, pdf, png, jpeg, Max. file size: 2 GB, Max. files: 3. Owner #2 ID Drop files here or Select files Accepted file types: jpg, pdf, png, jpeg, Max. file size: 2 GB. Business InformationBusiness Description*Business Structure* Sole Proprietor Partnership Corporation Non-Profit Card Present*Card NOT Present*Internet (Ecommerce Only)*Start Date* Month Day Year Currency* USD CDN Seasonal Business?* No Yes If Seasonal, from which month to which month?*Volume and SalesVisa $ (in the 1000s annually)*Mastercard (in the 1000s annually)*Interac $ (in the 1000s annually)*All Cash and Card Sales $*HIGH Transaction Ticket $*EquipmentList*Equipment TypePrice Per UnitQuantityRent- Purchase - LeaseTotal Add RemoveTotal Equipment Price*Purchase Installments 6 months 12 months Company Void Check Drop files here or Select files Accepted file types: jpg, pdf, png, jpeg, Max. file size: 2 GB, Max. files: 3. Any other docs you have can be uploaded here Drop files here or Select files Accepted file types: jpg, pdf, png, jpeg, Max. file size: 2 GB, Max. files: 3. Is there an alternative shipping address ?* No Yes Alternative Shipping Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Notes** PROMO DISCLAIMER:*** Merchant AgreesMerchant account must be actively and continuously processing for 12 consecutive months and be in good standing throughout this promo timeframe. Maintain a minimum processing volume of $3000.00 per month in credit card transactions to qualify for any promo. NPS reserves the right to pay any promos in 2 installments. NPS also reserves the right to modify and remove any such promo as they see fit. *Note any merchants terminating/cancelling their account with NPS will not qualify for any promo rebate* Closer Name* Δ
