Merchant Quick App Worksheet

COMPANY INFORMATION

Merchant Website: Corporate/Legal Name * :

This field is required

Doing Business As Name: Business Type: Products/Services: Corporate/Legal Address: City: State: Zip: Physical Business Address: City: State: Zip: Incorporation/Start of Business Date: Federal Tax ID (if applicable): Business Type:
Business Phone: Business Fax:

COMPANY SHAREHOLDERS

First Name * :

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Last Name * :

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Percent of Ownership: Title: Address Line 1: City: State: Zip/Postal Code: Date of Birth: Social Security Number: Phone Number * :

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Email Address * :

This field is required

Please Enter Valid Email Address

FORECASTED INFORMATION

Average Ticket Amount: Highest Ticket Amount: Bank Name: Routing Number: Account Number: