docusign

BUSINESS INFORMATION

Legal/Corporate Name:

DBA:

Physical Address:

City:

State:

Zip:

Telephone #:

Fax #:

Federal Tax ID:

Date Business Started:

Length of Ownership:

Website:

Email Address:

Type of Entity (check one):

Sole ProprietorshipPartnershipCorporationLLCOther

Type of Business (check all that apply):

RetailMO/TOWholesaleRestaurantSupermarketOther

Product/Service Sold:

MERCHANT/OWNER INFORMATION

Corporate Officer/Owner Name:

Title:

Ownership %:

Home Address:

City:

State:

Zip:

SSN:

Date of Birth:

Home #:

Cell #:

PARTNER INFORMATION

Partner Name:

Title:

Ownership %:

Home Address:

City:

State:

Zip:

SSN:

Date of Birth:

Home #:

Cell #: