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Network Application Form
Your Name
(Required)
First
Last
Your Address
(Required)
Street Address
Address Line 2
City
ZIP Code
How Can We Reach You?
We would love to chat with you. How can we get in touch?
Your Email Address
(Required)
Email Address
Confirm Email Address
Your Phone
(Required)
Best Time to Call You
(Required)
Select A Time
12:00 am
12:30 am
1:00 am
1:30 am
2:00 am
2:30 am
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3:30 am
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8:30 am
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11:30 am
12:00 pm
12:30 pm
1:00 pm
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6:30 pm
7:00 pm
7:30 pm
8:00 pm
8:30 pm
9:00 pm
9:30 pm
10:00 pm
10:30 pm
11:00 pm
11:30 pm
What is your method of selling or producing the sale?
How do you sell your products?
Please click all that apply
(Required)
100% Online (mobile)
In Person Sales (Dispensary, Lounge, Puff & Paint)
Third ChoiceMix of Online & Phone sales
Phone (Production Facility, Cultivating)
Other
Legal Name of Business (TAX FILING NAME, as it appears on your income tax return)
(Required)
Business Type (S-Corp, Sole Prop, LLC, etc.)
(Required)
Is business publicly traded, registered with the SEC, or not-for-profit? If publicly traded [NYSE or NASDAQ], list ticker
(Required)
Website Address
(Required)
STREET ADDRESS of Business (TAX FILING Address, as it appears on your income tax return)
(Required)
FEDERAL TAX ID No
(Required)
PRINCIPAL’S FULL NAME & OWNERSHIP %
(Required)
Please list each individual who directly or indirectly (through any contract arrangement, understanding, relationship, or otherwise) owns 10% or more of the equity interests of the specified legal entity.
Does any other individual (s) meet the 10% ownership definition specified above?
(Required)
Yes
No
If Yes, please also submit the additional owner (s) information above.
STREET ADDRESS, City, State, Zip of Business – Business street address (if yes above)
BUSINESS TELEPHONE
(Required)
BUSINESS CUSTOMER SERVICE TELEPHONE
(Required)
BUSINESS CONTACT EMAIL
(Required)
PRINCIPAL’S #1 SOCIAL SECURITY #
(Required)
PRINCIPAL’S #1 Date of Birth
(Required)
PRINCIPAL’S 1 Phone – Cell or Home
(Required)
PRINCIPAL’S #1 HOME ADDRESS
(Required)
PRINCIPAL’S #2 SOCIAL SECURITY #
PRINCIPAL’S #2 Date of Birth
PRINCIPAL’S #2 HOME ADDRESS
PRINCIPAL’S 2 Phone – Cell or Home
PRINCIPAL’S 2 Email (Can't be the same as PRINCIPAL’S #1)
PRINCIPAL’S 3 Phone – Cell or Home
PRINCIPAL’S #3 Date of Birth
PRINCIPAL’S #3 HOME ADDRESS
PRINCIPAL’S #3 SOCIAL SECURITY Number
PRINCIPAL’S 3 Email (Can't be the same as PRINCIPAL’S #1 or #2)
What state is the business incorporated in?
(Required)
The business must be domiciled in one of the 40 states and the District of Columbia in the United States where Cannabis is legal.
Who is your Cannabis Compliance Tracking System provider?
(Required)
Example: Metrc / Biotrack
Is there an ATM onsite? If yes, what is the funding source?
(Required)
Is your primary institution aware that you are an MRB engaged in activity that is subjected to the Cole Memo?
(Required)
DATE BUSINESS OPENED/ACQUIRED:
(Required)
Number of Employees
(Required)
What type of account do you need?
(Required)
Retail Payments
ACH Processing
Check 21 Processing
Minority Program
Other
Does this company offer Delta-8 Products?
(Required)
Does this company offer Kratom-derived products?
(Required)
What is the current Bank Name for your deposit?
(Required)
Current Bank Routing for merchant deposits
(Required)
What is the routing number for your bank account?
Current Bank Account for merchant deposits?
(Required)
What is the full account number for the deposits
Have you ever had a payment card processing relationship terminated: (have you been placed on MATCH)
(Required)
Who is your current payment provider?
(Required)
If no payment processing, just enter no.
Are any beneficial owners a Politically Exposed Persons (PEP)? If yes, name of PEP, country of affiliation and title:
(Required)
Does your company accept cash?
(Required)
Does your company accept bitcoin or other non-fiat methods of payment? If so, list the processor or method by which this occurs.
(Required)
Type of Terminal you use
(Required)
Do you operate a cashless ATM that mimics a real ATM?
(Required)
Who is your debit provider, if any?
(Required)
AVERAGE TICKET PRICE
(Required)
The average transaction price per customer
HIGHEST TICKET PRICE
(Required)
What is the largest transaction amount for one customer shopping in your store?
How did you hear about us?
(Required)
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Phone
This field is for validation purposes and should be left unchanged.
Phone
+1 (914) 758 5200
Email
Dpalmer@paymentfunnels.com
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