BUSINESS INFORMATION

Legal Name (as it appears on IRS documents)

Legal Address Line 1

Address Line 2

City

State

Zipcode

Phone Number

Fax Number

Length of Time Owned
Years Months

Federal Tax ID

Business Type (Corporation, LLC, Nonprofit)

Billing Contact Name

Billing Contact Phone

Billing Contact Email

Average Sale (the usual transaction amount)

Estimated Annual Credit Card Sales

OWNER INFORMATION

Copy of a current driver's license (please upload a photo)

Home Phone Number

Email

Social Security Number*

BANKING INFORMATION

ABA or Routing Number (9 digits)

DDA or Account Number (funds deposit)

*all sensitive information is secured and destroyed in compliance with the Payment Card Industry Data Security Standard and all other regulations that may apply.