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Business Information
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Legal Name of Business
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Mailing Address
*
City
*
State
*
Zip
*
Phone #
Fax #
*
Contact Name
*
Email Address
Business URL
Federal Tax Name
Federal Tax Number
Business Structure
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Partnership
Corp. (LLC, S or C)
Non-Profit
*
State Filed
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DBA
(doing business as)
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Location Address
Same as Mailing
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City
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State
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Zip
Estimated
Average ticket
High ticket
Estimated Monthly Volume
Visa/Mastercard
Discover
American Express
Personal Information
Owner/Partner 1
*
Ownership Percent
+51%
-
50%
*
Name
(first, last)
*
Title
*
Home Address
*
City
*
State
*
Zip
*
Phone #
SSN
D.O.B.
Owner/Partner 2
is required
*
Name
(first, last)
*
Title
*
Home Address
*
City
*
State
*
Zip
*
Phone #
SSN
D.O.B.
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Bank Information
Deposit Bank
Routing number
(9 digits)
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Account number
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American Express MID
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