ePay Application Form Please complete our secure form to set up your merchant ePay account Which Version of ePay Are You Applying For? ePay - Standalone Payments ePay - Full emilyEMR Integration Number of Wired Terminals - $10/mo Number of Wireless(WiFi)Terminals - $20/mo Company Information Legal Business Name DBA: doing business as name (if different than legal business name) Description of the products/services the business offers Business legal address (where records are kept) Business address if different from legal address Business start date Business address if different from legal address Business phone number General business email Government business number (i.e. CRA Tax ID, IRS, etc) Company Structure Private Company Public Company Sole Proprietorship Website URL Business document (eg. incorporation, business registration, business license etc.) Attach banking info (eg. void cheque or deposit form) Processing Information Monthly credit card sales revenue Average Transaction size (ie., $500) Minimum Transaction size Maximum transaction size Frequency of Maximum Transaction/yr (Number of times per year) Amex Monthly Card Sales in $ Do you want to accept AMEX? Yes No How long after paying does the customer receive what they purchased? Ownership Information Owner First Name Owner Last Name Owner Home Address Owner Home Address Owner home phone or cell number Owner email address Percentage of ownership (if applicable) Owner date of birth SSN or SIN (Social Security or Social Insurance Number) Owner driver’s licence (driver's licence #, province, issue date and expiry date) ePay Terms and Conditions I Accept ePay Terms and Conditions SUBMIT