payments - Excel Media Group

Payment Gateway Setup Form

Step 1 of 3

Business Name(Required)

Business Phone Number(Required)

Business Registration number

Business Address(Required)

Street Address City State ZIP Code

Business type(Required)

Sole Proprietorship

Partnership

Corporation

Other

Full Name(Required)

First Last

Personal Address(Required)

Street Address City State ZIP Code

Personal Phone(Required)

Date of Birth(Required)

Please choose(Required)

Social Security Number (SSN)

Individual Taxpayer Identification Number (ITIN)

Social Security Number (SSN)(Required)

Individual Taxpayer Identification Number (ITIN)(Required)

Identification documents (driver’s license, passport, etc.)(Required)