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Nextera Payments – Business Profile Form

Business Legal Name with Applicable DBA*

Business Type*

Federal Employer Identification Number (EIN#)*

Business Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Applicant Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Social Security Number (SSN)*

Your SSN is only used for verification of identity.

Date of Birth (DOB)*

Secondary Applicant Name (If Applicable)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Social Security Number (SSN)

Your SSN is only used for verification of identity.

Date of Birth (DOB)

Existing Business Annual Revenue

Please provide your Annual Revenue amount for the prior year for Existing Businesses

New Business Projected Revenue

Please provide the projected Annual Revenue for your new Business

Voided Check*

Drop files here or

Max. file size: 256 MB, Max. files: 2.

PLEASE UPLOAD A CLEAR IMAGE OF A VOIDED CHECK FOR BANK DEPOSITS – YOUR ACCOUNT WILL NOT BE CREATED WITHOUT THIS

Phone

This field is for validation purposes and should be left unchanged.