PMA Form | Creditor

1. Lawful Overview

Legal name *

Entity Type *

TIN Type *

Federal Tax ID/EIN *

Address *

Suite

City *

State *

ZIP *

Phone *

Email *

2. Business Address

Address *

Suite #

City *

State *

ZIP *

3. Contact Details

First Name *

Last Name *

Phone *

Email *

Chargeback Notification

Chargeback Email

4. Owner(s)

Primary Owner

First Name *

Last Name *

Title *

Ownership % *

Personal Phone *

Individual With Control? *

Address *

City *

State *

ZIP *

DL Number *

State Issued *

Issue Date *

Exp Date *

Date of Birth *

Social Security Number *

Prior Bankruptcy

5. DBA Overview

Name *

Business Type *

Business Start Date *

Years In Business *

Address *

Suite #

City *

State *

ZIP *

Location Type *

Square Feet

Phone *

Vertical Type

Products & Services Sold

Website

Card Holder Descriptor

6. Sales Profile

Extended Obligations *

Uses Affiliate Marketing? *

Advertising Method *

Straight Sale Billing

Monthly Billing

Average Ticket *

High Ticket *

Monthly Volume *

Annual Volume *

Estimate sales initiation methods (must equal 100%)

Total: 0%

Estimate sales groups (must equal 100%)

Total: 0%

7. Customer Service

Who Provides CS? *

Center Name

Phone *

8. Fulfillment Process

Who Provides Fulfillment? *

Where Is Product Stored? *

Fulfillment House Name

Shipping Service Used

Delivery Time Frame

9. Bank Information

Account Type *

Name *

Name on Account *

Routing # *

Account # *

10. Supporting Documents

Upload in PDF, JPG or PNG format.

Articles Of Org *

SS-4 Letter *

Voided Check

Government ID *

Business Statement 1

Business Statement 2

Business Statement 3

Personal Statement 1 *

Personal Statement 2 *

Personal Statement 3 *

Customer Service Agreement

Fulfillment Agreement

CRM Agreement

Chargeback Agreement

COA's

1. Lawful Overview

Legal name *

Entity Type *

TIN Type *

Federal Tax ID/EIN *

Address *

Suite

City *

State *

ZIP *

Phone *

Email *

2. Business Address

Address *

Suite #

City *

State *

ZIP *

3. Contact Details

First Name *

Last Name *

Phone *

Email *

Chargeback Notification

Chargeback Email

4. Owner(s)

Primary Owner

First Name *

Last Name *

Title *

Ownership % *

Personal Phone *

Individual With Control? *

Address *

City *

State *

ZIP *

DL Number *

State Issued *

Issue Date *

Exp Date *

Date of Birth *

Social Security Number *

Prior Bankruptcy

5. DBA Overview

Name *

Business Type *

Business Start Date *

Years In Business *

Address *

Suite #

City *

State *

ZIP *

Location Type *

Square Feet

Phone *

Vertical Type

Products & Services Sold

Website

Card Holder Descriptor

6. Sales Profile

Extended Obligations *

Uses Affiliate Marketing? *

Advertising Method *

Straight Sale Billing

Monthly Billing

Average Ticket *

High Ticket *

Monthly Volume *

Annual Volume *

Estimate sales initiation methods (must equal 100%)

Total: 0%

Estimate sales groups (must equal 100%)

Total: 0%

7. Customer Service

Who Provides CS? *

Center Name

Phone *

8. Fulfillment Process

Who Provides Fulfillment? *

Where Is Product Stored? *

Fulfillment House Name

Shipping Service Used

Delivery Time Frame

9. Bank Information

Account Type *

Name *

Name on Account *

Routing # *

Account # *

10. Supporting Documents

Upload in PDF, JPG or PNG format.

Articles Of Org *

SS-4 Letter *

Voided Check

Government ID *

Business Statement 1

Business Statement 2

Business Statement 3

Personal Statement 1 *

Personal Statement 2 *

Personal Statement 3 *

Customer Service Agreement

Fulfillment Agreement

CRM Agreement

Chargeback Agreement

COA's