Apply | Vice Pay™ Merchant Application

Business information

The legal details, as they appear on your tax return.

Legal business name *

DBA / trade name (if different)

Entity type *

EIN / Tax ID *

State of formation *

Date established (MM/YYYY)

Years in business *

Business phone *

Business email *

Website / store URL(s)

Business address *

Mailing address (if different)

Business profile

What you sell and how — this drives which bank we route you to.

Industry / vertical *

Describe your products / services and who you sell to *

# of locations

# of employees

% B2B

% B2C

Seasonal? (Y/N)

Return / refund / cancellation policy

Delivery / fulfillment timeframe

Advance billing? (Y/N + days)

Ownership

Everyone who owns 25% or more. Required for bank KYC.

Owner 1

Full legal name *

Title *

Ownership % *

Date of birth *

Home address *

Mobile phone *

Email *

We don’t collect SSNs here. Owner SSNs are gathered on the signed application we send after you apply, so sensitive ID data never travels through this web form.

Processing profile

How you take payments today.

Services requested

Credit / Debit ACH / e-check Online gateway Terminal / POS

Avg monthly volume *

Average ticket *

Highest ticket

% Card present

% Keyed / MOTO

% E-commerce

Currently processing? *

Yes No / first time

Reason for leaving / seeking a new processor

Ever terminated or on MATCH/TMF? *

No Yes

Chargeback ratio, last 6 mo (%)

Can you provide your last 3 months of card processing statements? (strengthens your file)

Yes No New business — none yet

No upload needed yet. If you have them, you’ll attach your last 3 months of processing statements (and bank statements) through the secure link we send after you apply.

Funding & compliance

Where deposits go, plus the items your vertical requires.

Bank name

Account type

Account & routing numbers come later. You’ll provide a voided check and full account details on the signed application, not on this page.

Licenses held (FFL, pharmacy, alcohol, etc.)

Age-verification in place? (Y/N)

States you ship / sell to

Legal opinion letter on file? (Y/N)

LegitScript / VIPPS certified? (Y/N/NA)

COA available for products? (Y/N/NA)

Products ≤ 0.3% THC? (Y/N/NA)

Agreeable to a reserve if required? (Y/N)

Requested go-live date

Documents & signature

Tell us what you can provide, then certify and sign.

Documents you can provide

Voided check or bank letter Photo ID for each owner (25%+) 3 months of bank statements 3 months of processing statements (if processing) 2 yrs tax returns / financials (if over $100K/mo) Vertical docs (COA, FFL, license, legal opinion letter, as applicable)

I certify the information provided is true, complete, and accurate, and that the business operates lawfully and in compliance with all card-brand rules and applicable laws. I authorize Vice Pay and its sponsoring banks and processors to investigate this information, including credit and background checks on the business and its owners. I understand this application does not guarantee approval.

Signature — type full name *