JURIS PAYMENTS MERCHANT APPLICATION
Call For Question 866-931-4878
Required items are marked with (*)
Step 1 of 4
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You are on your way to increasing your sales and profits by accepting credit cards for your business.
For your privacy and security, your account information is kept safe with the highest grade of commercially available encryption. Your information will be kept completely confidential and will not be shared with anyone.
In order to complete the setup and activation process and start accepting credit cards from your customers, please provide us with the information requested below to the best of your knowledge, fields that you don’t know or that you are not sure about please leave blank.
User IP address 203.189.151.98
Company Contact
*
Best Contact Phone
*
Doing Business As (DBA) if applicable:
Email Address:
*
Enter Email
Confirm Email
Information About the Company
Legal Name of Business (as it appears on your tax return):
*
Federal Tax Id Number (Sole Owners may use SSN):
*
Business Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Business Phone Number:
*
Business Website (if applicable):
Owner Information
Owner's Legal Name:
*
First
Last
Owner's Residence Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Owner's Social Security Number (for I.D. verifcation purposes only):
*
Owner's Date Of Birth:
*
MM
DD
YYYY
Business Information
Products or Services Sold (i.e. Cab Service):
*
Type of Ownership
*
Sole Ownership
Partnership
Public Corp
Private Corp
Non Profit/Tax Exempt
Limited Liability Corporation (LLC)
Government
Name of the Bank you want your funds deposited:
*
Routing/Transit Number:
*
Account Number:
*
Trust Account Number:
I have verified my bank account number and routing number to be correct
*
Yes I have verified my bank account and routing number
Total Monthly Credit Card Sales (estimated):
*
Please Pick Your Free Equipment Package
*
Payment Gateway/ with Software Integration
Stationary Ingenico EMV/NFC Terminal
Payment Gateway/ with Mobile App
I have read and agree to
Pricing
,
Free Terminal Agreement
,
Terms of Service
, and
Operating Guide
Please Sign the box below, click and move mouse to sign the box
*
NOTE: It is okay if your signature appears different than normal
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