Business Information Form

Legal Name of Business:

DBA (doing business as):

Street Address:

City:

State:

Zip Code:

Mailing Address (if different):

City:

State:

Zip Code:

Business Phone Number:

Business Fax:

Merchant Email:

Date Business Acquired:

List Type of Business:

Merchant URL:

Federal Tax ID:

Number of Employees:

Type of account needed:

Retail
Internet
MOTO
Petroleum

Estimated Monthly Volume: $

Typical Ticket Amount:$

Highest Estimated Ticket: $

Will you accept Amex?

Yes
No

Existing Amex Service Number:

Business Bank Routing Number:

Business Bank Account Number:

Ownership Information

Type of Ownership:

Percentage of Ownership:

Officer’s Name:

Officer’s Title:

Date of Birth:

Social Security Number:

Driver’s License #:

State Issued:

Expiration Date:

Home Address:

City:

State:

Zip Code:

Home Phone Number:

*Please enter the Bold Letters of the Code provide below, Form is Case Sensitive