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 *
Sole ProprietorCorpLLC

Description of business / Products Sold *

EIN / Federal Tax Id # *

Business Email Address *

Business Owner Name *

Additional Business Owner Name(s):

Owner’s Home Address *

Telephone No:

Email Address *

Ownership % *

Deposit Bank Name (Attach Pre-Printed Voided Check) *

Upload Check *

Bank Routing # *

Bank Account # *

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):