Sign up with goEBT Step 1 of 2 50% How did you hear about goEBT.com?A goEBT.com Representative Called MeInternet SearchSocial Network (Facebook, Twitter, etc.)AdvertismentFriendIndustry ReferralFNS SNAP Authorization #*Full Legal Business Name*Authorizes CDE Services, Inc. and its designated financial institution, and the financial institution listed below to transfer funds and make correcting debit adjustments, when needed, to the indicated business account for activity related to the Electronic Benefit Programs subject to the terms of the Service Agreement. Store Location InfoStore Name*Store Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Store Telephone Number*Contact E-mail Address* Enter Email Confirm Email Please choose the appropriate tax classification:*Individual/Sole ProprietorC CorporationS CorporationPartnershipTrust/estateLimited liability companyLLC Tax classification:*C = C Corporation S = S Corporation P = PartnershipOwner InformationOwners Name* First Last Mailing Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Business Phone*Title*OwnerOfficerChecking Account InformationAccount to which EBT transfers will be made AND fees will be ACH debited.IMPORTANT NOTICE: All ACH Blocks and/or Filters MUST be cleared with your bank for the following Company ID’s prior to Agreement Approval and commencing Processing services: Company ID #581878009 Company ID #13199664X9 Name of your bank*Routing or ABA #*Confirm Routing or ABA #*Checking Account #*Confirm Checking Account #*Business License InfoThis info must match the information registered with your Tax ID Number. Registered Business Name*Doing Business As (d/b/a)Business Address* Same as Store Location Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Federal Employer ID Number*orSocial Security Number*Electronic redemption with POS equipment. (cash benefits may not be available in all states.)Primary Method of Benefit Redemption*Retailer will support one of the following methods of Redemption:Food Stamps and Cash BenefitsFood Stamps Benefits onlyCash Benefits onlyHow many devices sets will be needed?*Device set includes one terminal and one pin pad12345678910How would you like to connect your terminal?*Phone LineInternetService Provider reserves the right to collect any outstanding fees or charges from any of Service Providee’s pending EBT Transactions prior to settling funds into Service Providee’s account. IN WITNESS WHEREOF, the Parties have caused this Agreement to be executed the day and year first above written. Printed Name* First Last Checking Account Confirmation** Account to which EBT transfers will be made AND fees will be ACH debited By checking this box and confirming the checking account information above, I confirm that I accept the terms of this agreement and, per my typed or written signature above, I am authorized to accept this agreement. {all_fields}
