Vaulted Security Pre-Application

Ownership Information

List Ownership Details for Owners with 25% or More Ownership
Owner 1 Name:*

First NameLast Name
Owner 1 Title:*
Owner 1 SSN:*
Owner 1 Phone Number:*
Please enter a valid phone number.
Owner 1 Date of Birth:*

MonthDayYear
Date
Owner 1 Length of Ownership:*
Owner 1 Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner 1 Email:*
example@example.com
Owner 1 Ownership Percentage:*
Owner 1 Driver's License:

Cancelof
Owner 2 Name:

First NameLast Name
Owner 2 Title:
Owner 2 SSN:
Owner 2 Phone Number:
Please enter a valid phone number.
Owner 2 Date of Birth:

MonthDayYear
Date
Owner 2 Length of Ownership:
Owner 2 Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner 2 Email:
example@example.com
Owner 2 Ownership Percentage:
Owner 2 Driver's License:

Cancelof
Owner 3 Name:

First NameLast Name
Owner 3 Title:
Owner 3 SSN:
Owner 3 Phone Number:
Please enter a valid phone number.
Owner 3 Date of Birth:

MonthDayYear
Date
Owner 3 Length of Ownership:
Owner 3 Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner 3 Email:
Owner 3 Ownership Percentage:
Owner 3 Driver's License:

Cancelof
Owner4 Name:

First NameLast Name
Owner 4 Title:
Owner 4 SSN:
Owner 4 Phone Number:
Please enter a valid phone number.
Owner 4 Date of Birth:

MonthDayYear
Date
Owner 4 Length of Ownership:
Owner 4 Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner 4 Email:
Owner 4 Ownership Percentage:
Owner 4 Driver's License:

Cancelof

Banking Information
Bank Name:
Routing Number:
Account Number:
Upload Image of Voided Check or Bank Reference Letter

Cancelof
Upload Image of your 501(c)(3) Articles:

Cancelof

Activity & Features
Estimated Annual Sales (all payment types):
Enter in whole dollars
Estimated Monthly Sales on Credit Cards:*
Enter in whole dollars
Average Ticket Amount: *
Enter in whole dollars
Type of Business:*
High Ticket (highest total one customer would need to be approved on card):*
Enter in whole dollars

Pricing Model:*

Cash Discount / Dual PricingInterchange PlusFlat RateTiered
Interchange Plus Pricing:
Cash Discount/Dual Pricing Rates:
Flat Rate Pricing:
Tiered Pricing:
Monthly Fees (if not needed, input a 0):*

Final Notes:
Enter Summary or Additional Details Needed for Setup:
Additional Vaulted Security services you want to us to review for savings:

Business PhonesWebsite ProposalCyber Security/BackupsCustom Workflows
Upload Most Recent Phone Statement for a review:

Cancelof
Should be Empty:

	Card Present	Card Not Present
Ethernet Terminal
Wifi Terminal
Mobile Terminal
Invoicing
E-Commerce
Virtual Terminal
Recurring

Vaulted Security Pre-Application

Ownership Information

Banking Information

Activity & Features

Terminal & Batch Settings

Final Notes: