Business Owner’s Full Name
Business Name (Legal Name, As Found on tax returns)
Business Name (DBA, If Different From Legal)
Company Email Address
Contact Phone
Business Phone
Legal Address(As Found On Tax Returns)
Location Address (No P.O. Box)
Website Url (If Applicable)
Business Type (Check All That Apply) RetailEcommerceWholesaleOther
Business Structure Sole ProprietorPartnershipCorporationLLCNon-ProfitOther
Federal Tax Id#
Type Of Goods Or Services Sold
Federal Tax Id
Years In Business
Are you Currently Accepting Credit Card? YesNo
Ownership%
Title
Date Of Birth
Drivers License # | Issuing State | EXP Date
Home Address
Have The Owners/Principals Ever Filed Never FiledPersonalBusiness
Have The Owners/principals Ever Been Terminated From Accepting Bankcards For This Business Or Any Other Businesses?
Notes
Most Recent Processing Statement
12+48=?
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