Business Information
Contact Name:
Business DBA Name:
DBA Address:
DBA City, ST, Zip:
DBA Phone:
DBA Fax:
Click here if the legal information is NOT the same as the DBA
Tax Background and Information
Federal Tax ID:
(or Principal Owner's SSN)
Email Address:
Ownership Type:
Years in Business:
Owner / Principal #1
First Name:
Last Name:
Home Address:
Home City, ST, Zip:
Home Phone or Cell:
Social Security # :
Ownership %:
Add Additional Owner:
Average Monthly Volumes

Please estimate in the fields below your estimated monthly credit sales. Especially important are average sales ticket and highest sales ticket. Inaccuracies may cause a delay in funding pending risk investigation. Please enter whole dollar amounts. Do not include $ or .00.

Average Sales Ticket:
Highest Sales Ticket:
Average Monthly Volume:
Percentages of Business

In this section we want to estimate the percent of business which will be obtained in each of the 3 categories below. Please be sure all three entries total 100%.

% Swiped: % Help
% Keyed w/imprint: % Help
% Mail/Telephone/Internet: % Help
Business Reference

Please enter a trade reference from your field which can be any vendor or affiliate of the company.

Company Name:
Contact Name:
Phone Number:
Additional Information
Type of merchant Account:
Sales Rep Name:
Describe the products and services you sell:
Comments:
 

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