Gym Assistant Sign-up Form

If you are a management company completing this application on behalf of a client, this information should be for your client's business.

Legal Name * The legal name is the name that was registered with the secretary of state

DBA Name Name that the business operates under that isn't its legal business name

Federal Tax ID *

NAICS *

Business Phone *

Legal Structure *

Year Established *

State Established *

Website * Enter your website, Facebook, Instagram, YouTube or other social media platform page.

Address

Physical Address Line 1 *

Physical Address Line 2

City *

State *

Zip *

Primary Contact

Person we can contact to ask questions regarding this application or ACH processing issues once your account is live.

Name *

Title *

Phone *

Billing Contacts

Same as Primary Contact

Name of Billing Contact #1 *

Title *

Business Phone *

Name of Billing Contact #2 (Optional)

Title

Business Phone *

Beneficial Owner Information

If no single owner has 25% or more equity, please identify the managing partner or executive.

Same as Primary Contact

Name *

Title *

Percentage Owned *

Business Phone *

Email *

SSN *

Date of Birth *

Driver's License *

State Issued *

Home Address Line 1 *

Home Address Line 2

City *

State *

Zip *

Transaction Information

The information below should reflect what you think your activity will look like in about 6 to 12 months.

How will you receive authorization from your customers to process payments via ACH? (Select all that apply) *

Contracts signed by my customers (PPD) contract with consumer / (CCD) contract with businesses

Purpose of Debits *

How frequently do you anticipate processing debit transactions? *

Number of debits per month you'll process *

Total value of debits you'll process in a month *

Largest single debit you'll want to process *

Purpose of Credits *

How frequently do you anticipate processing credit transactions? *

Number of credits per month you'll process *

Total value of credits you'll process in a month *

Largest single credit you'll want to process *

Bank Information

Please provide information for the bank account to use for processing your payments.

Bank Name *

Routing Number *

Account Number *

Please provide information for the bank account to use for your billing.

Bank Name

Routing Number *

Account Number *

Gym Assistant Sign-up Form

Company Information

Address

Primary Contact

Billing Contacts

Beneficial Owner Information

Transaction Information

Bank Information