Merchant Info Sheet

Legal Name of Business *

DBA Name (if different from legal)

Legal Business Address: *

Address Line 1

City

State

Zip Code

DBA Address (if different from legal)

Address Line 1

City

State

Zip Code

Authorized Contact (Auth. Contact is authorized to act on owner’s behalf

First

Last

Authorized Contact Birthday *

Business Phone *

Federal Tax ID *

Email Address (will be used for owner 1 to e-sign if applicable) *

Business Type *

Years in Business *

Length of ownership *

Merchandise/Service Sold *

Monthly CC Volume (estimated) *

Highest Ticket (estimated) *

Average Ticket (estimated) *

Owner 1 Name *

First

Last

% Ownership *

Owner 1 Social Security # *

Owner 1 Birthday *

Owner 1 Phone # *

Owner 1 Driver’s License # *

DL State *

DL expiration date *

Owner 1 Address *

Address Line 1

City

State

Zip Code

Add Another Owner? *

Do you have more owners with 25% or more ownership? *