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Repair Shop Payments — Application Intake Form

Which Program Would You Like To Move Forward With?

Which Program Would You Like To Move Forward With?
A
B
C

Business Legal Name

DBA Name If Different From Corporate Name

Business Start Date

Month and year preferred

EIN

Found on your IRS SS-4 form or any prior tax document

Average Monthly Ticket

Leave blank if you have already provided statements

Average High Ticket

Leave blank if you have already provided statements

Average Monthly Credit Card Sales Total

Leave blank if you have already provided statements

Driver's License

Front side only

Voided Check

Must include your business name — not a starter check
Your SSN will not be collected here. Derek will call you directly before sending your DocuSign application to collect this securely over the phone.