* - Required Field

- More information

Section 1- Company Contact Information

Legal Name Of Supplier*

DBA (required if different than Legal Name)

Physical Address*

City*

Country*

State*

Postal/ZIP Code*

Phone*

Website*

Does your business currently accept a commercial credit card for B2B payments (P Card or Virtual card, not a consumer or corporate card)*

Section 2- Company Ownership Information

Boost Payment Solutions partners with regulated financial services institutions and, as such, we are required to obtain certain information to comply with Anti-Money Laundering (AML)/ Know Your Customer (KYC)/ Financial Crimes Reporting requirements via the Bank Secrecy Act, USA Patriot Act, and Financial Crimes Enforcement Network (FINCEN) regulations. The information requested is dependent on your entity type. This information is not used for any purpose by Boost other than to meet federal regulations. Boost maintains strict protocols for information and data security as well as confidentiality and privacy.

Federal Tax ID*

Description of Goods or Services*

Appropriate Entity*

Does your business have any beneficial owners with 25% or greater ownership?*

Owner Name*

Owner Address*

Owner City*

Owner State*

Owner Zip Code/Postal Code*

Owner Email*

Owner Date of Birth*

Owner Social Security Number*

Owner Ownership Percentage*

Are there any other Beneficial Owners with 25% or great ownership in the company?*

Owner 2 - Name*

Owner 2 - Address*

Owner 2 City*

Owner 2 State*

Owner 2 Zip Code*

Owner 2 Email*

Owner 2 - Date of Birth*

Owner 2 - Social Security Number*

Owner 2 - Ownership Percentage*

Are there any other Beneficial Owners with 25% or great ownership in the company?*

Owner 3 - Name*

Owner 3 - Address*

Owner 3 City*

Owner 3 State*

Owner 3 Zip Code*

Owner 3 Email*

Owner 3 - Date of Birth*

Owner 3 - Social Security Number*

Owner 3 - Ownership Percentage*

Are there any other Beneficial Owners with 25% or great ownership in the company?*

Owner 4 Name*

Owner 4 Address*

Owner 4 City*

Owner 4 State*

Owner 4 Zip Code*

Owner 4 Email*

Owner 4 Date of Birth*

Owner 4 Social Security Number*

Owner 4 Percentage Ownership*

Control Person Name*

Control Person Address*

Control Person City*

Control Person State*

Control Person Zip Code/Postal Code*

Control Person Email*

Control Person Date of Birth*

Control Person Social Security Number*

Control Person Percentage Ownernship*

Upload IRS issued document including Federal Tax ID. Acceptable forms include SS-4, 147c or W-9.*

Add File...

Type of Nonprofit*

Region where services are performed*

Principal/Control Person Name*

Principal/Control Person Address*

Principal/Control Person City*

Principal/Control Person State*

Principal/Control Person Zip Code/Postal Code*

Principal/Control Person Email*

Principal/Control Person Phone*

Principal/Control Person Date of Birth*

Principal/Control Person Social Security Number*

Stock Exchange Ticker Symbol*

Authorized Signatory Name*

Authorized Signatory Address*

Authorized Signatory City*

Authorized Signatory State*

Authorized Signatory Zip Code*

Authorized Signatory Email*

Authorized Signatory Title*

Section 3- Remittance Information

Boost will need either a voided check or a bank letter on bank letterhead that provides the bank account details for funding so we can deposit the funds into your preferred bank account. This is required to meet Anti-Money Laundering (AML)/ Know Your Customer (KYC)/ Financial Crimes Reporting Network (FINCEN) regulations.

Remittance Contact Name*

Remittance Contact Email*

Upload voided blank check or banking information on bank letterhead.*

Add File...

Section 4- Authorization

This form should be completed by someone who is authorized to sign on behalf of the company. Please complete the following information for the authorized signatory.

Authorized Signatory Name*

Authorized Signatory Title*

Authorized Signatory Email*

Authorized Signatory Phone*

This contact will also be used for product and account updates. If you'd like these communications directed to another member of the company, please select the check box to continue.

Primary Contact Name*

Primary Contact Email*

Primary Contact Title*

This application will not be processed unless and until all required information is provided, including information regarding the company’s beneficial owners with 25% or greater (if applicable), and Supplier's voided check(s) or bank letter(s) are submitted.

Terms and Conditions

Boost Services. This Card Processing Application and Agreement (“Agreement”) is made by and between the business named in the application (“Supplier”) and Boost Payment Solutions, Inc. (“Boost”). This Agreement includes the attached application, pricing information, and other applicable schedules and documentation provided by Boost in connection with this Agreement. Boost, as a registered payment facilitator of Worldpay, LLC and its sponsoring bank, Fifth Third Bank (collectively, “Acquirer”), will provide Supplier with acquiring and payment processing services (“Services”) in accordance with the terms of this Agreement.

Read full terms and conditions here

Direct Acquirer Agreements. In the event Supplier’s processing volume exceeds the thresholds established by a Payment Network, or if the Rules otherwise require a direct agreement between the Acquirer and Supplier, then, in addition to being bound by this Agreement, Supplier will automatically be deemed to have accepted, and will be bound by, the “Merchant Services Agreement for Sub-Merchants” with Acquirer which is set forth at https://www.boostb2b.com/boost-stp-additional-terms, the terms of which will be independently enforceable by Acquirer. Unless otherwise agreed to by the parties, Amex processing will require Supplier to have a direct acceptance agreement with Amex, pursuant to which Amex will provide and be responsible for all settlement funding for Amex transactions.

SUPPLIER AGREES TO PAY THE PUBLISHED INTERCHANGE RATES AT THE TIME EACH TRANSACTION IS SETTLED PLUS A PROCESSING FEE OF 0.54% FOR ALL TRANSACTIONS (SUBJECT TO CHANGE AS PROVIDED IN THE AGREEMENT). View current straight through processing rates for Visa and Mastercard here.

By clicking the checkbox below, Supplier and its Authorized Signatory represent, certify, and acknowledge that Supplier has read, understands, and agrees to comply with the terms and conditions of this Agreement, and that all information provided in the application is true, complete, and accurate.

Supplier is responsible for ensuring that such information remains current throughout the term of the Agreement and agrees to update Boost promptly upon any changes (including but not limited to changes to Supplier’s Authorized Signatory or Beneficial Owner(s), or other account information).

I Agree*

Date Signed*

Terms and Conditions Submitted

Boost Services. This Card Processing Application and Agreement (“Agreement”) is made by and between the business named in the application (“Supplier”) and Boost Payment Solutions, Inc. (“Boost”). This Agreement includes the attached application, pricing information, and other applicable schedules and documentation provided by Boost in connection with this Agreement. Boost, as a registered payment facilitator of Worldpay, LLC and its sponsoring bank, Fifth Third Bank (collectively, “Acquirer”), will provide Supplier with acquiring and payment processing services (“Services”) in accordance with the terms of this Agreement.

READ FULL TERMS AND CONDITIONS HERE
https://www.boostb2b.com/boost-intercept-terms

SUPPLIER AGREES TO PAY THE PUBLISHED INTERCHANGE RATES AT THE TIME EACH TRANSACTION IS SETTLED PLUS A PROCESSING FEE OF 0.54% FOR ALL TRANSACTIONS (SUBJECT TO CHANGE AS PROVIDED IN THE AGREEMENT).

Direct Acquirer Agreements. In the event Supplier’s processing volume exceeds the thresholds established by a Payment Network, or if the Rules otherwise require a direct agreement between the Acquirer and Supplier, then, in addition to being bound by this Agreement, Supplier will automatically be deemed to have accepted, and will be bound by, the “Merchant Services Agreement for Sub-Merchants” with Acquirer which is set forth at https://www.boostb2b.com/boost-stp-additional-terms/, the terms of which will be independently enforceable by Acquirer. Unless otherwise agreed to by the parties, Amex processing will require Supplier to have a direct acceptance agreement with Amex, pursuant to which Amex will provide and be responsible for all settlement funding for Amex transactions.
VIEW CURRENT STRAIGHT THROUGH PROCESSING RATES FOR VISA AND MASTERCARD HERE
By clicking the checkbox below, Supplier and its Authorized Signatory represent, certify, and acknowledge that Supplier has read, understands, and agrees to comply with the terms and conditions of this Agreement, and that all information provided in the application is true, complete, and accurate.

Supplier is responsible for ensuring that such information remains current throughout the term of the Agreement and agrees to update Boost promptly upon any changes (including but not limited to changes to Supplier’s Authorized Signatory or Beneficial Owner(s), or other account information).

Rate Submitted

SUPPLIER HEREBY AGREES TO PAY APPLICABLE PUBLISHED INTERCHANGE RATES PLUS 0.54% AT THE TIME EACH TRANSACTION IS SETTLED.

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