Merchant application

Apply for processing

This is the Payzli Connect merchant application. Submit sends it for boarding. You will finish bank linking and e-sign in Payzli’s email flow.

Staging demo — the form is pre-filled with sandbox test data. Hit submit to send it to Payzli Connect demo.

Contact information

First name * Last name * Email * Phone *

Business information

Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations.

Business legal name * DBA name Tax filing name *

Tax filing method *

EIN SSN

Tax ID (EIN / SSN) * Type of ownership *

Stock exchange

NYSE / NASDAQ Other / N/A

Stock ticker Industry (MCC) Business description

Industry options

Quasi cash

Business start date * Website Business phone *

Business address

Street address 1 * Street address 2

City * State *

ZIP * Country

Mailing address

Same as business address

Street address 1 Street address 2

City State

ZIP Country

Business owner information

Individuals who own 25% or more, or who control the business.

First name * Last name * Street address 1 Title * % ownership *

Personal guarantee

Yes

SSN Date of birth * Mobile phone Email Street address 2 City State ZIP Country

Additional business owner (optional)

First name Last name Street address 1 % ownership SSN Date of birth Mobile phone Street address 2 City State ZIP Country

Bank account

Deposit / withdrawal account for settlement.

Bank name * Account type Routing number * Account number * Est. annual card volume Average ticket Card present % Card not present % Online %

Confirmation & agreement

Payzli Connect boarding. You are applying for merchant processing with Payzli. Underwriting, pricing, bank linking, and e-sign are completed in Payzli Connect after this application is received.

Accuracy. You certify the information is true and authorize Payzli and its partners to run credit and KYC checks needed to board the merchant account.

Processor: Payzli · Support 813-565-9999

Client initials * Print business legal name * Personal guarantee signature * Personal guarantee date * Agreement signature * Agreement date * Title * Print name of signer * Notes (optional)

I certify that the information is correct and I agree to submit this application to Payzli Connect for merchant boarding.

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