Agent's Name

Please provide your information below.

First Name *

Last Name *

Owner's Address *

Owner's City *

Owner's State *

Owner's Zip Code *

Email *

Mobile Phone Number *

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MERCHANT INFORMATION

Legal Business Name *

Type of Ownership *

Federal Tax ID # *

Address *

City *

State *

Postal code *

Incorporated State *

Business Phone Number *

Business Start Date *

Complete if different from LEGAL NAME

Merchant Business Name (Doing Business As)

DBA Address

DBA City

DBA State (Abbreviation Only)

DBA Zip Code

OWNERS/OFFICERS/PARTNERS

Social Security Number (First Seven Digits) *

Date of birth *

Bankruptcies Within The Last Five Years? *

Yes

OWNERS/OFFICERS/PARTNERS

Do You Have 100% Equity Ownership? *

Yes

OWNERS/OFFICERS/PARTNERS

Owner One Equity Ownership %

Owner Two Equity Ownership %

OWNERS/OFFICERS/PARTNERS

Owner/Principal #2 Name

Owner/Principal #2 Residence Address

Owner/Principal #2 City

Owner/Principal #2 State

Owner/Principal #2 Zip Code *

Owner/Principal #2 Date of Birth

Owner Two: First Seven Digits of Social Security Number

Owner/Principal #2 EMAIL

Owner/Principal #2 Phone Number