Diadem Business Technologies

NAVIGATION

SOCIAL

ADDRESS (NY FINANCIAL DISTRICT) 1 LIBERTY PLAZA 165 BROADWAY 23RD FLOOR NEW YORK, NY 10006

CONTACT info@diademtechnologies.com 877-274-6652

APPLICATIONS

LET’S GET STARTED Welcome to our Application Submittal Portal. Please fill out each field and include all supporting documents

“We lead the way to opening new opportunities for growth” - Darryl W. Elliott

MERCHANT PRE APPLICATION

Merchant Pre-Application

Please fill out the fields below.

Business Legal Name *

DBA Name *

Business Address *

Business Phone *

Business Fax:

Business Website URL *

Business Email

Contact Name

Phone

Contact Email

Type Of Entity *

Fed Tax ID *

Month/ Year Started *

Number Of Employees *

Product/ Services Sold *

Hours of Operation *

Total Gross Annual Sales *

Annual Credit/Debit Card Sales *

Average ($) Credit/Debit Card Individual Sales Amount *

Estimated Highest ($) Credit/Debit Card Individual Sales Amount *

What percent is Credit/Debit Card *

What percent is Web based / Gateway *

What percent is Mail / Phone Order *

Number of Inside Processing Terminals *

Number of Outside Processing Terminals *

Signer/ Owners Name *

Signer Title *

Signer Percent of Ownership *

Signer Social Security Number *

Signer Date of Birth *

Signer Home Phone *

Signer Home Address *

Deposit Bank Name *

Bank Routing Number *

Bank Checking Account Number *

Bank Phone Number *

Due Diligence Documentation: * Voided check or Bank Letters Driver License or Passport (for Each Signer/Principal Business License or Articles of incorporation/ Organization or Operating Agreement

Documentation

POS System *

Payment Terminal/ PIN Pad * Ingenico Lane 3000 Ingenico Lane 5000 Reveal Ingenico Move 5000 Ingenico iSelf Series Ingenico iUC285 Online Gateway Integration

Sales Office *

Rep Name *

Rep Email *

Rep Phone *

Comments *

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