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Basic Business Information

DBA (Doing Business As) Name:

Business/Corp Name:

Location Address:

City:

State:

ZIP Code:

Contact Information

Business Phone Number:

Email:

Bank Information

Bank Name:

Name on Bank Account:

Check Account #:

Bank Routing #:

Federal Tax ID:

TIN Type: EIN SSN

Business Details

Type of Merchant: Sole Proprietor
Partnership
LLC
Corporation
Non-Profit
Other

Statement Option Type: Electronic    Paper

Business Processing Category: Retail    Restaurant    MOTO    Internet    Other

Merchandise/Services Sold:

Currently accept Visa/MasterCard/Discover/AXP? Yes    No

Active Month: January    February    March    April    May    June    July    August    September    October    November    December

Avg Ticket:

High Ticket:

Avg Monthly Volume:

High Monthly Volume:

Owners and Officers

Owner Name:

Owner Title:

Owner SSN:

Owner Date of Birth:

Owner Equity Ownership:

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