Business Information Form

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Please complete the business information form and our team will review your details.

Sensitive details are saved in a private server folder outside public_html and are not visible from the website.

Legal Business Name*

DBA Name if different

Legal Business Address*

DBA Address if different

Legal Business Telephone No*

DBA Telephone No*

Type of Business Entity

Description of business / Products Sold*

EIN / Federal Tax ID #*

Business Email Address*

Business Owner Name*

Additional Business Owner Names if any

Owner’s Home Address*

Telephone No

Email address*

Ownership %*

Deposit Bank Name, please attach pre printed voided check*

Upload*

Bank Routing #*

Bank Acct #*

Approx. yearly volume

Average Ticket

Yearly V/C, M/C Disc volume

Approx. High Ticket

American Express Volume yearly

EBT / FNS # if applicable

Type of equipment required

Special Comments if any

Are you human?