First Name

Last Name

Title

Phone

Email Address

Business Name

Please classify your business

Business Website

BACK END SOURCE

Original Response ID

What's more common for you?

How did you hear about us?

Since you selected "Other", please elaborate!

Do you currently take cards?

Do you accept EBT cards?

Enter your FNS number.

REQUIRED if you take EBT

What goods/services will you be accepting credit cards for?

Are you working with an Account Representative?

Please input your Account Representative's name:

What questions do you have about a new account?

Help us understand your business! We'll use these values for fraud prevention and risk mitigation, so please be as accurate as you can.

Enter your monthly Visa/MasterCard/Discover credit-card volume.

$

If your monthly volume fluctuates, input your largest month

Enter your monthly American Express volume.

$

AMEX sales will fund with Visa/MasterCard sales at great low rates

Enter the average transaction size you typically process

$

Calculate by dividing your monthly volume by the number of sales

Enter the largest transaction size you'll regularly expect to process.

$

To help us protect you from fraud, what's the biggest sale you'll take?

IRS Classification

Taxpayer ID (EIN)

Listed on your tax returns
Please do NOT include dashes.

Legal Business Name

When did the business form?

Legal Street Address

City

State

Zip

Legal phone number

Is the DBA (Doing Business As) info exactly the same as above? This is what customers see when you run their card.

DBA Street Address

City

State

Zip

DBA phone number

DBA Street Address

City

State

Zip

DBA phone number

Select your refund policy:

How many days until delivery?

You'll answer "0" if you sell in-person

Describe your refund/return policy.

Please describe your typical sales flow, from beginning to end.

How do you promote/advertise your products or services?

What is the name of your current processor?

Why did you decide to leave your current processor?

Bank Account Information

This account will be for your deposits and fee withdrawals. You'll get paid for your gross deposits throughout the month, and then our fees will be automatically debited from the below bank account on a monthly basis.

Bank Name

Routing Number

This is always 9 digits long.

Account Number

Federal law requires us to identify individuals who own 25% or more of a business when opening financial accounts. Note; all owners don't have to sign the application, but we need to know who they are. How many owners with at least 25% equity are there?

You may have one or two signers. Only signers can make future account updates. If there is regular turnover between positions in your organization, we highly recommend having two signers, as future updates are much easier after one signer leaves the organization. How many signers will there be?

Signer 1

All of the below requested information is required. Each signer's Social Security Number will be required when you electronically sign the DocuSign application we email to you.

First Name

Last Name

Title

Email Address

Phone

Home Address

City

State

Zip

Date of Birth

This is required for identity verification.

Percentage Ownership

%

What % of the business does the signer own?

2nd Signer/Owner

All of the below requested information is required. Each signer/owner's Social Security Number will be required when you electronically sign the DocuSign application we email to you.

First Name

Last Name

Title

Email Address

Please use a DIFFERENT email address than the first signer - we require a unique email.

Phone

Home Address

City

State

Zip

Date of Birth

This is required for identity verification.

Percentage Ownership

%

What % of the business does the signer own?

3rd Owner

All of the below requested information is required. Each owner's Social Security Number will be required when you electronically sign the DocuSign application we email to you.

First Name

Last Name

Title

Email Address

Please use a DIFFERENT email address than the first signer - we require a unique email.

Phone

Home Address

City

State

Zip

Date of Birth

This is required for identity verification.

Percentage Ownership

%

What % of the business does the signer own?

4th Owner

All of the below requested information is required. Each owner's Social Security Number will be required when you electronically sign the DocuSign application we email to you.

First Name

Last Name

Title

Email Address

Please use a DIFFERENT email address than the first signer - we require a unique email.

Phone

Home Address

City

State

Zip

Date of Birth

This is required for identity verification.

Percentage Ownership

%

What % of the business does the signer own?

Your Customers

Help us understand who your customers are. Please fill in the below boxes with your best estimations for who you accept credit cards from:

Consumers %	Businesses %
Governments %	Total %

Card Acceptance

Let us know what percentage of your sales are swiped, keyed, or online.

Card Present %	Key-Entry %
Internet % Please note! If you're processing internet sales AND card-present retail sales, we may require a separate account for your eCommerce transactions, per Visa/MC guidelines. Your salesperson will assist with this step if necessary.	Total %

Recurring Payments

If you automatically bill your clients at specific intervals, please adjust the below. If you only charge your customers once and don't save their payment information, you can skip this.

One-Time %	Monthly %
Quarterly %	Total %

Equipment Options

Please select how you intend to process:

Free MX Merchant for virtual terminal and iPhone/Android ProcessingStandalone terminals such as First Data or ValorPay terminalsClover POS such as Mini, Flex, Compact, or StationAuthorize.net gatewayExisting Equipment or Software that I'm bringing to DharmaNone of these apply

Please explain how you intend to process payments, since none of the above apply.

MX Merchant

All Dharma accounts come with free access to MX Merchant. This includes a Virtual Terminal, Customer Database,, and Phone app.

Are you interested in the following optional MX Products?

MX BT Swiper (swipe / dip / tap) - $149 eachB2B Processing App - $20/monthInvoicing App - $10/monthMX Advantage for Surcharging App - $25/monthACH Processing - $25/month, 0.20% + $0.40/txn

How many USB-swipers?

Gateway Options

Authorize.net Fees

$

Thanks for choosing Authorize.net. As a reminder, ALL new Authorize.net accounts will include access to an online Virtual Terminal, Automated Recurring Billing, and Customer Information Manager. Ongoing monthly fees are paid directly to Authorize.net. Fees are $10/month and $0.05/transaction. The billing cycle will start when you activate the account, so you can hold off until you're ready. Anything else we should know about? Now's your time to share!

Please enter any additional information that may be important.

Clover Options

Which Clover system do you want to purchase?

How many Clover Station Duos would you like to purchase? Clover station costs $2,0999 each. Stations comes with a customer-facing Mini, and high-speed printer.

clover station duo(s)

How many Clover Mini devices would you like to purchase? Clover Mini is $949 per device.

clover mini(s)

How many Clover Flex devices would you like to purchase? Clover Flex is $749 per device.

clover flex units

Clover Flex Pocket

How many Clover Flex Pocket devices would you like to purchase? Clover Flex Pocket is $599 per device.

clover flex pocket units

Clover Compact

How many Clover Compact devices would you like to purchase? Clover Compactt is $299 per device.

Clover Compact units

Clover Accessories

Clover Mini device: Let your customers pay by interacting with the Clover Mini. It interfaces directly with Clover Station for a seamless experience - your customers can use Apple Pay, input PIN codes, and opt to receive electronic receipts - all without any employee interaction.

Clover Mini device(s) at $949 each

Clover Flex device: With Clover Flex devices, you can have a handheld payment experience. Servers/employees can complete a full transaction with customers all through the flex, including PIN Debit and printing.

Clover Flex device(s) at $7499 each

Clover Flex Pocket device: With Clover Flex Pocket devices, you can have a handheld payment experience. Servers/employees can complete a full transaction with customers all through the flex, including PIN Debit.Includes 4G/LTE connectivity (requires data plan for cellular usage)

Clover Flex Pocket device(s) at $599 each

Kitchen Display System: An employee-facing device that displays order management software connecting the front-of-house and online ordering platforms to the kitchen staff. Designed solely for restaurants, the Clover Kitchen Display System is used where food and beverage orders are prepared in place of paper tickets.

Kitchen Display System(s) at $799 each

Kitchen Printer: Built to withstand the heat and humidity of the kitchen, this fast, two-color printer offers crisp, easy to read type for quick viewing. When you use it with Clover, you can even print orders in different languages. This is the only kitchen printer compatible with Clover.

Kitchen Printer(s) at $399 each

Weight Scale: Frozen yogurt shops and other merchants who sell their wares by weight can speed up checkout with our integrated weight scale. This scale supports up to 20lbs, switches easily between grams and ounces, and automatically passes weight information into Clover for a quick and accurate checkout process.

Weight Scale(s) at $399 each

Barcode Scanner: A barcode scanner helps you speed up checkout lines and manage your inventory with ease. Virtually any 1D or 2D barcode can be captured, and will integrate with your Clover inventory.

Barcode Scanner(s) at $159 each

Label Maker: A label maker allows you to easily create printed labels for your products. The Brother QL-710W Label Printer is capable of printing up to 93 labels per minute, so you won't waste time setting up inventory. This wireless label maker allows you to create custom labels for price stickers, barcodes, address labels, or postage. This works perfectly with the "Easy Labels" app!

Label Maker at $399 each

Cash Drawer: A cash drawer is an important part of any Point-of-Sale system! f you’re using the Clover Station or Clover Mini, a cash-drawer is an optional accessory. It includes a standard bill tray, coin tray, and 2 keys for the lock.

Cash Drawer(s) at $99 each

Swivel Stand: The Mini is designed to stay “in place” on your countertop. With the swivel, your Clover Mini instantly becomes “customer facing” so that you can spin the unit towards the customer for PIN-debit , or to request email/phone information.

Swivel Stand(s) at $99 each

Please note! Clover is a product that is managed/serviced directly by First Data. As such - Clover has some specific conditions around how the hardware works, and the policies associated with it. We'll send details via DocuSign, but the main takeaways are: Clover Systems are non-transferable. Once you purchase Clover with Dharma, you can't bring that hardware to another service provider. This is a First Data restriction that applies to all Clover resellers like Dharma. In addition, there is a $250 restocking fee for all Clover products, and you must return them within 30 days should you change your mind. Please be sure that Clover is the solution for you, as there are hard costs associated with returning Clover POS.

I understand and agree.

Total Clover Costs:

$

All Clover Setup Fees will be withdrawn from account on file upon approval.

Please Review your Clover Setup Fees for accuracy.

Clover Station Duo Costs

Station Pro includes 14" Touchscreen, Clover Mini, and High-Speed Printer

Quantity:

x $2099 =

Total

$

Clover Mini Costs

Quantity:

x $949 =

Total

$

Clover Flex Costs

Quantity:

x $749 =

Total

$

Clover Flex Pocket Costs

Quantity:

x $599 =

Total

$

Clover Compact Costs

Quantity:

x $299 =

Total

$

Clover Accessory Costs

KDS Quantity. x $799 =	Total $
Kitchen Printer Quantity: x $399 =	Total $

Weight Scale Quantity:

x $399 =

Total

$

Barcode Scanner Quantity:

x $159 =

Total

$

Cash Drawer Quantity:

x $99 =

Total

$

Swivel Stand Quantity:

x $99 =

Total

$

Label Maker Quantity:

x $399 =

Total

$

Business Documentation

The following documents must be submitted for final application approval. Please securely submit all documentation below. If you're unable to electronically submit your documentation, you may fax documents to (415) 632-1921, or email directly to your sales representative.

Proof of Business Entity

You can upload a 501c3 document, business license, articles of incorporation, or tax document.

Voided Check

We'll need proof of your bank account. That proof can either be a pre-printed, voided check, OR a signed bank letter on bank letterhead detailing the account name, ABA routing number, and account number.

Driver's Licenses

Please upload current Driver's Licenses for each signer. Click the "Upload Another" button on the right to upload multiple files.

Previous Processing Statements

Please upload your past three months' processing statements from your current provider. Click the "Upload Another" button on the right to upload multiple files.

Nonprofit Tax Exempt Certificate

If you are a tex exempt nonprofit, in order to ensure you are not charged tax on any equipment purchase, please upload your Tax Exempt Certificate.

Additional Documents (optional)

Please upload any other documentation that may be relevant to a new merchant account. This could include marketing materials, purchasing contracts, customer agreements, business financial documents, pricing lists, or any other documentation that may not be available on your website, yet is important for us to know!

By clicking “Submit” you agree to share your personal and business data with Dharma Payments LLC, for our use in determining if we can support you with a merchant processing account. Submission does not guarantee you will be approved for an account. If Dharma is unable to support you with a merchant processing account, we may, at our discretion, share basic contact information with a partner who may be able to support you. If we do, you will be informed, and that partner will contact you directly. If you do not agree with these terms, please close the window without clicking Submit and your data will not be captured or saved

Your data will never be sold or brokered to any third party. You can review our Privacy Policy here .