A Merchant Processing Application is required to be accurately and completely filled out and its contents attested to by a responsible individual for each entity (or subsidiary/affiliate) for every entity that receives Salucro’s payment processing services (referred to as the “merchant”). See the MPA Client Info Sheet for more information about these obligations.
Please note, if your organization has more than one legal entity, one Application must be completed for each separate legal entity within a client organization that will receive Salucro processing services. Accurate details regarding the merchant are essential for creating the processing account and compliance with legal obligations.
1. Legal Entity Name: Legal name of the merchant as it appears in filings with the state, e.g., the certificate of incorporation or formation).
2. DBA Name: Doing Business As (if applicable).
3. Business Tax Identification Number (TIN/EIN): Business tax identification number as filed with the IRS. Please enter no more than 9 digits and do not include any dashes.
4. Registered Physical Business Office: Physical address where the merchant operates.
5. Ownership Type: As registered with the state of formation:
6. What Merchant Category Code (MCC) Best Describes the Merchant’s Business: The four-digit number that classifies the type of services the merchant offers.
7. Business Phone Number: General phone number utilized for the merchant’s business operations.
8. Business Email Address: General email address utilized for the merchant’s business operations.
9. Business Website: Business website address/URL. Please include “http(s)://” in your response.
10. Date of Incorporation: The date the merchant was approved to do business in its state of formation.
11. State of Incorporation: The state of formation where the merchant was approved to do business.
12. Billing Contact Name: Best contact individual affiliated with the merchant for billing specific items.
13. Billing Contact Address: Business address of the billing contact identified above.
14. Billing Contact Phone Number: Business phone number of the billing contact identified above.
15. Billing Contact Email Address: Business email address of the billing contact identified above.
1. Beneficial Ownership: Do any individuals hold 25% or more ownership interest in the merchant (directly or indirectly). If yes, toggle to indicate “yes” and fill out required owner information to follow.
2. Beneficial Ownership #2: After completing the required information for beneficial owner #1, the merchant must indicate whether there are other owners with 25% or more ownership. If yes, toggle to indicate “yes” and fill out required owner #2 information to follow.
3. Additional Beneficial Owners: For subsequent beneficial owners (up to 4 total), please continue to follow the steps above to ensure all owners are listed as required.
4. No Beneficial Owners: If there are no individuals with direct or indirect ownership, toggle the next option to “Yes” to provide an individual with significant responsibility to control, manage or direct the merchant. If none of the 25%+ owners have been designated as the Control Individual, then also select "Yes" to identify a single individual with significant responsibility to control, manage, or direct the Merchant.
Bank Account Demand Deposit Account Type: Indicate whether the account listed is a checking or savings account.
Bank Account ACH Type: Indicate whether the account listed is a private or business account.
Routing Number: Enter the routing number associated with the bank account listed.
Confirm Routing Number: Re-Enter the routing number associated with the bank account listed.
Account Number: Enter the Account number associated with the bank account listed.
Confirm Account Number: Re-Enter the Account number associated with the bank account listed.
Average Ticket (USD): Merchant’s average payment amount per patient.
Monthly Volume (USD): Merchant’s average monthly credit card processing amount.
The individual completing the application on behalf of the merchant is attesting that all information submitted in the Merchant Processing Application is complete and accurate. Further, this individual represents and warrants that the individual has requisite power and authority to submit this application on behalf of the merchant and initiate merchant processing services.