[Vivid] New Merchant Intake Form

Tell Us What Solution You're Interested In

What Solution Would You Like?

Which Model?

Which Plan Are You Interested In?

Option 1: Purchase

Option 2: Payment Plan

Option 3: Lease

Option 4: Merchant Owned

Quantity:

Please Specify Product:

Tell Us A Little About Yourself

Full Name:

Email Address:

Phone Number:

Tell Us About Your Business

Legal Business Name:

Doing Business As (DBA):

Type of Ownership:

Date Business Started:

Number of Locations:

Product / Service Sold:

Federal Tax ID Number:

Website:

Bank Name:

Bank Account # (DDA):

Bank Routing # (ABA):

How Would You Like To Pay For The Hardware?

Bank Account On File (above)

Credit Card (additional 2.9% fee)

Already Owned

Credit Card Number

Expiration Date

Security Code

ZIP Code

I hereby authorize VividPayments, LLC to charge the above account for the hardware selected in Section 1 of this application.

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Which Address Would You Like The Hardware Shipped Too?

Legal

Physical

Other

Tell Us More About Your Business

Is Your Physical Location Address The SAME As Your Corporate Address?

Yes

Indicate if Classified as:

Small Business

Disadvantaged Business

None

Tell Us About Your Sales

Do you currently accept Visa/MC/Discover® Network?

Yes

Estimated Average Ticket Amount

Estimated High-End Ticket Amount

Estimated Monthly Card Volume ($)

Estimated Monthly Amex Volume

How Do You Plan On Accepting Payments? (Use Percentages)

% Store Front/ In-Person

% Phone Order (Keyed)

% Internet Services

Tell Us More About Your Sales

What is your return, cancellation, or refund policy?

What % of sales are with international cards?

Who owns product?

Merchant

Vendor (Drop Ship Required)

Are consumers required to provide a deposit?

Yes

What is the Deposit Percentage:

Tell Us About Your Ownership

Name

Title

Date of Birth

Social Security Number

Ownership %

Are there any other Owners that own 25% or more?

Yes

Name

Ownership %

Date of Birth

Social Security Number

Upload Driver's License and Voided Check

Additional Questions/Comments?