Card Form

Store Info

STORE NAME:

STREET ADDRESS:

CITY: STATE: ZIP:

STORE PHONE:

STORE EMAIL ID:

Business Info

LEGAL NAME OF BUSINESS:

Is Legal Addresss different from Store Address? YES NO

FEDERAL ID#:

FNS NO (If Foodstamp Required):

(If Foodstamp Required)

FIRM TYPE (INC / LLC / CORP):

(INC / LLC / CORP)

YEAR COMPANY WAS ESTABLISHED:

Owner Details

OWNER'S FIRST NAME:

LAST NAME:

HOME ADDRESS (STREET):

CITY: STATE: ZIP:

CELL PHONE:

DATE OF BIRTH:

OWNERSHIP (%):

SSN NO:

EMAIL ID:

Bank Info

BANK NAME:

ACCOUNT NUMBER:

ROUTING NUMBER:

Credit Card Terminals

NO. OF TERMINALS: ESTIMATED TERMINAL PRICE: $ 0

*Copy of following documents are required
1) Owner's Driver License
2) Business Voided Check
3) SS-4 Form
4) The most Recent Statement from your current processor