BusinessIQ

PRODUCTS

^*Select the product(s) you are applying for

BUSINESS INFORMATION

^*Legal Business Name

Doing Business As (DBA Name)

Tax ID

^*Physical Address

^*City

^*State/ Province

^*Zip/Postal

Country

^*Telephone - Work

^*Email Address

^*Type of Business

^*Number of Employees

^*Year Business Established

^*Preferred Contact Method? (Business Email, Business Phone, and/or Mail)

^*Nature of Business:

^*Number of years under current ownership:

^*Have you ever been declined ACH Origination or Remote Deposit Capture Services?

If yes, please describe:

^*Does your company currently originate ACH entries?

^*Does your company currently use Remote Deposit Capture?

^*Do you conduct business out of the United States?

If yes, please provide locations

^*Has any principal/owner of the business declared Bankruptcy?

If yes, please provide date filed:

^*Gross Annual Sales for previous year:
$

^*Number of locations:

Do you have an existing deposit or loan account with CU?

If yes, please provide Account #:

ACH ORIGINATION

LIMIT REQUESTED:
$

ESTIMATED NUMBER OF ACH FILES SENT MONTHLY:

ESTIMATED MONTHLY DOLLAR VOLUME:
$

ESTIMATED MAX AMOUNT OF ANY ACH FILE:
$

ESTIMATED MAXIMUM AMOUNT OF ANY ACH TRANSACTION:
$

ACCOUNT NUMBER USED FOR FEES/CHARGES:

ACCOUNT NUMBER USED FOR FUNDING:

WHAT TYPE OF FILES WILL BE SENT?

SEASONAL ACH FILES OR TRANSACTIONS:

SEASONAL ACH FILES REPRESENTING:

IF OTHER, PLEASE PROVIDE:

REASON FOR SEASONAL ACH FILES:

ESTIMATED DOLLAR AMOUNT FOR SEASONAL ACH FILES:
$

GENERAL ACH FILES REPRESENTING:

IF OTHER, PLEASE PROVIDE:

FREQUENCY OF ACH PAYROLL FILES SENT:

WEEKLY ON

BI-WEEKLY ON

MONTHLY ON

Other

FREQUENCY OF ACH TAX PAYMENT FILES SENT:

MONTHLY ON

QUARTERLY ON

SEMI-ANNUALLY ON

Other

WHAT IS THE ESTIMATED MONTHLY DOLLAR VALUE FOR THE TRANSACTIONS FILES INDICATED BELOW?

PAYMENTS
$

PAYROLL
$

TAX PAYMENTS
$

Other

ADDITIONAL INFORMATION FOR ACH FILES MAY BE ENTERED HERE:

REMOTE DEPOSIT CAPTURE

Daily RDC Limit Requested

NUMBER OF SCANNERS:

HIGHEST DAILY DEPOSIT DOLLAR AMOUNT:
$

HIGHEST # OF CHECKS IN A SINGLE DEPOSIT:

HIGHEST SINGLE DEPOSIT $ AMOUNT:
$

HIGHEST # OF CHECKS DEPOSITED EACH DAY:

HIGHEST NUMBER OF DEPOSITS MADE EACH DAY:

HIGHEST DOLLAR AMOUNT OF RETURNED ITEMS IN A MONTH:
$

HIGHEST NUMBER OF ITEMS RETURNED EACH MONTH:
$

ADDITIONAL INFORMATION FOR REMOTE DEPOSIT CAPTURE USAGE MAY BE ENTERED HERE:

PRINCIPAL/OWNERSHIP INFORMATION

^*Principal Title

^*Principal First Name

^*Principal Last Name

^*Principal Home Address

^*City

^*State/ Province

^*Zip/Postal

^*Telephone - Home

^*Telephone - Cell

^*Principal Email Address

^*Principal Social Security Number (SSN)

^*Principal Drivers License State

^*Principal Drivers License Number

^*Principal Date of Birth

^*Principal Ownership %
%

^*Billing Address

^*City

^*State/ Province

^*Zip/Postal

Principal Title

Principal First Name

Principal Last Name

Principal Home Address

City

State/ Province

Zip/Postal

Telephone - Home

Telephone - Cell

Principal Email Address

Principal Social Security Number (SSN)

Principal Drivers License State

Principal Drivers License Number

Principal Date of Birth

Principal Ownership %
%

Billing Address

City

State/ Province

Zip/Postal

Attachments

Please attach documents relevant to the application decision process (i.e., company financials, relevant license information, etc)

Attachment Description

Attachment Location

Note: Accepted file formats include PDF, CSV, TXT and various image files (JPEG, JPG, GIF, BMP, TIFF, TIF, PNG, ICO). File attachments must not exceed 10 MB in combined size.

Terms and Conditions

^*Signature of Applicant

^*Title

^*Date

PRINT AGREEMENT

I agree to the terms and conditions specified above.

User Verification

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