Application - Remote Deposit

* indicates required field

Business Information

*Corporate / Legal Name
DBA Name
*Physical Address
Address (cont.)
Federal Tax ID #
*Zip/Postal Code
*Phone Number
Fax Number
Customer Service Phone #
Website Address / URL
Number of Locations
Days & Hours of Operation
Time Zone

Billing Information

Billing Address (if different)
Billing Address (cont.)
Zip/Postal Code

Contact Information

*Primary Contact Name
*Phone Number
SSN or 9-digit PIN
Secondary Contact Name
Phone Number
SSN or 9-digit PIN


ACH Payment Types (ACH ONLY)
Services Requested (check all that apply)

Check Conversion - ARC

Internet Check (web-based)

Back Office Conversion

Preauthorized Recurring Payments - Debits

Point of Purchase - POP

Preauthorized Recurring Payments - Credits

Issue Credit

Preauthorized Single Debit Payment


Telephone Check

Merchant Capture - Check 21 ONLY (Scan Check - Remote Deposit)

Check Conversion

If selecting BOTH C21 and ACH please indicate if EPS' component should automatically determine how a scanned consumer check is to be processed:

Yes - All consumer check will be processed via ACH when possible

No -- All consumer check will be processed via C21



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