Merchant Application

Your Information

First Name*

Last Name*

Are you the authorized signer for this business?*

Yes No

Your email*

Your phone number*

Your title*

DBA Location Information

DBA name of location*

Location Type*

Retail WEB Both Retail and WEB

Street address (no P.O. box)*

City*

State*

Zip*

County*

Phone Number*

Website Address*

Average monthly total monthly sales*

$

Average ticket per sale*

$

POS Provider*

Other*

State Marijuana License Types?*

Medical Recreational/Retail Both None

State License Expiration Date(s)*

Is this location required to have local city/county marijuana license(s)?*

Yes No

How many Recreational/Retail CanPay Terminals will be needed?*

How many Medical CanPay Terminals will be needed?*

Would you like to include a Multi-Tablet Charging Stand(s) (1 charges 7 tablets at a time, $79 per charger)

Where should hardware be shipped?*

To DBA To Legal Other

Name of person receiving hardware*

Location Reporting Information

Password*

Confirm Password*

What email should reports be sent to?*

Legal Entity Information

Check if Legal Address is same as DBA address

Legal Entity Name*

Street Address*

City*

State*

Zip*

Federal Tax ID*

Business Type*

Corporate Contact Name*

Title*

Phone Number*

Email*

If CanPay needs to contact you regarding legal matters related to your merchant status, changes to our terms and conditions, or other instances where we need to contact your legal representative, please indicate that contact below:*

DBA Address / Authorized Signer Legal Address / Authorized Signer Other Legal Representative or Different Authorized Signer (such as a registered agent, corporate counsel, or other)

Name*

Title*

Email*

Address*

City*

State*

Zip Code*

Authorized Signer Information

Full Name*

Title*

Social Security Number*

Date of Birth*

Signer's email address (application will be sent here to sign)*

Residence Street Address*

City*

State*

Zip*

Phone Number*

Bank Deposit Information

Financial Institution Name*

Financial Institution Contact Person (your banker)*

Financial Institution Contact Person E-mail Address

Routing Number*

Account Number*

I want to use a separate bank account for fees charged by CanPay

I will be submitting more locations using the same Legal and/or Authorized Signer Info*

Yes No

Your Information

DBA Location Information

Location Reporting Information

Legal Entity Information

Authorized Signer Information

Bank Deposit Information

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