Please provide the following information


BUSINESS LEGAL NAME:
TRADING AS (DBA):
BUSINESS LOCATION ADDRESS:
Street Address:
Address (cont.):
City:
State/Province:
Zip/Postal Code:
LANDLORD NAME:
LANDLORD PHONE NUMBER:

BILLING ADDRESS (if different):
Street Address:
Address (cont.):
City:
State/Province:
Zip/Postal Code:
BUSINESS PHONE NUMBER:
BUSINESS FAX NUMBER:
EMAIL ADDRESS:
WEB ADDRESS: http://www.
TYPE OF OWNERSHIP: CORP PARTNERSHIP SOLE PROPRIETOR LLC NON-PROFIT
FEDERAL TAX ID NUMBER:
AGE OF BUSINESS:
LENGTH OF CURRENT OWNERSHIP:

CHECKING ACCOUNT INFORMATION (account where funds will be deposited)
NAME OF BANK:
ROUTING NUMBER (9 digits):
ACCOUNT NUMBER:

1) OWNER / OFFICER:
PERCENTAGE OF OWNERSHIP:
HOME Street Address:
City:
State:
Zip/Postal Code:
DATE OF BIRTH:
HOME PHONE NUMBER:
SOCIAL SECURITY NUMBER:

2) OWNER / OFFICER:
PERCENTAGE OF OWNERSHIP:
HOME Street Address:
City:
State:
Zip/Postal Code:
DATE OF BIRTH:
HOME PHONE NUMBER:
SOCIAL SECURITY NUMBER:

Do You Currently Accept Credit Cards YES NO
IF YOU CURRENTLY ACCEPT ANY THE FOLLOWING CARD TYPES PLEASE INCLUDE YOUR MERCHANT ACCOUNT NUMBERS:
American Express:
DISCOVER:
DINERS:
JCB:

PLEASE ENTER YOUR BEST ESTIMATE OF THE FOLLOWING:
RETAIL SALES:	% (credit card is present and swiped through a terminal)
PHONE/MAIL ORDERS:	% (credit card is not present - card number is taken by phone or mail)
INTERNET ORDERS:	% (credit card is not present - card number is taken over the Internet)
TOTAL:	100%

MONTHLY CREDIT CARD VOLUME:	(estimated credit card sales per month)
AVERAGE TICKET AMOUNT:	(average amount per sale)
HIGH TICKET AMOUNT:	(largest amount you expect to have for a single credit card sale)

TRADE REFERENCES:
(Do Not List Bank Or Credit Card Accounts As Trade References)
NAME:	PHONE NUMBER:
NAME:	PHONE NUMBER:

DESCRIBE THE PRODUCT/SERVICE THAT YOU SELL:




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