New Merchant Information Form

DBA Name

DBA Address

City/State/Zip

DBA Phone

Email Address

Legal Name

Legal Address (if different from DBA)

City/State/Zip

Product/Service

Est Monthly Volume

Est Average Ticket

Ownership Type

( ) LLC( ) Corporation( ) Sole Proprietor( ) Partnership

Date Business Started

Federal Tax ID

Social Security #

Date of Birth

Signer Name

Home Address

City/State/Zip

Phone/Cell

Any other principals with 25% ownership? If so, please submit their info also.

Bank Name

Driver's license (optional)

(attach driver's license — PDF or image)Voided check (optional)

(attach voided check)

The information supplied will be used to complete the Merchant Processing Agreement. This form does not constitute a contract or agreement to do business with the Merchant Processor.