WELCOME The information below will be used to create your NRG Payments client file and generate applications for signature. All applications will be sent to the primary signer's email submitted on this form. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Business InformationDBA Name *Legal Business Name *Business Type *Business TypeSole ProprietorshipLLC/LLPC CorpS CorpCorporationGovernment501 cOtherEIN/Tax ID Number *Products & Services Sold *Average Ticket ($) *High Ticket ($) *Average Monthly CC Volume ($) *Average Monthly Amex Volume ($) *Amex monthly volume greater than $1M? *Amex monthly volume greater than $1M?YesNoAmex Account Number *Website URL *Business Email *Legal Business Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDifferent Mailing Address? *Different Mailing Address?YesNoMailing Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeTimezone *Banking InformationBank Name *Bank Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeName on Account *Account Type *Account TypeCheckingSavingsAccount Number *Routing Number *Principal InformationThe signer of the application.Name *FirstLastTitle *TitleOwnerPresidentCEOVice PresidentPartnerEquity Ownership (%) *Home Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code Amex Name Address Mobile Phone *Email *Social Security Number *Date of Birth *Driver License Number *Driver License State *Is there an additional owner to the one above? *YesNoTotal equity ownership for this section must add up to 75%Principal InformationThe 2nd signer of the application.Name *FirstLastTitle *TitleOwnerPresidentCEOVice PresidentPartnerEquity Ownership (%) *Home Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMobile Phone *Email *Social Security Number *Date of Birth *Driver License Number *Driver License State *DocumentationKYC * Click or drag a file to this area to upload. Please provide a color copy of a valid driver’s license or passport.Voided Check or Bank Letter * Click or drag a file to this area to upload. Please provide a copy of a voided check for the bank account you want funds deposited into. If you do not have checks, please provide a bank letter for the same account. Note: This should match the bank account information you provided above.Banking Statements * Click or drag files to this area to upload. You can upload up to 3 files. A. Please provide your three (3) most recent business banking statements. B. If your business account is brand new and you do not yet have three (3) statements, simply provide as many as you have available. C. If your business account is brand new and you do not yet have any statements, please provide your three (3) most recent personal banking statements.Processing Statements * Click or drag files to this area to upload. You can upload up to 3 files. Please provide your three (3) most recent processing statements.Corporate Docs * Click or drag files to this area to upload. You can upload up to 3 files. Please provide a copy of your articles of incorporation.EIN * Click or drag a file to this area to upload. Please provide a copy of your SS-4 letter from the IRS.Submit
