Business Information

Business Contact First Name

Business Contact Last Name

Business Contact Email Address

Legal Business Name

Doing Business As Name

If different from legal name

Business Street Address

Business City

Business State

Business Zip Code

Business Phone Number

Area Code of Business

If your account will be enabled with Texting options, this will be the area code sent with number to message recipient.

Time Zone of Business

Business Tax ID

Date of Registration

Business Type

LLC, Sole Proprietor, Inc., etc.

State of Registration

Average Sale Amount (Dollars)

Average Monthly Processing Dollar Volume

Website URL

Business Owner Information

Business Owner First Name

Business Owner Last Name

Business Owner Date of Birth

mm/dd/yyyy

Business Owner SSN

Owner Home Street Address

Owner Home City

Owner Home State

Owner Home Zip

% of Business Owned

for example: 56%

Funding Information

Bank Name

Bank Routing Number

This is the 9 digit number on your check.

Bank Account Number

Verify Bank Account Number

Exhibit A - Pricing Schedule

SwervePay Health Pro Software & Merchant Services Monthly Fees:

2.25% Swipe Processing Volume
2.95% Non Swipe Processing Volume
$0.30 Per Transaction
$30.00 Monthly Minimum Fee (only charged if monthly processing fees are less than $30.00)

One Time Fees

Card Readers (Device orders are non-refundable)

$130.00 IDTech M130 Card Reader w Keypad for Manual Entry

Setup and Training

$549 One Time Fee for Setup and Training Per Location

* Add'l Note(s)

Any additional information requests or notes for SwervePay Implementation and Deployment

Customer Service Contact Information

Customer Service Phone Number

Customer Service Email Address

Signer Information

Signer Full Name

Signer Title

Signer Email Address

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