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Legal Business Name
State
D.B.A.
Business Address
Suite
City/State/Zip
Describe Business (Name Product/Service)
Business Hours
% Mail Order
% Phone Orders
% Trade Show
# of Locs
Year Started
Fed Tax ID
State Tax ID (If Retail)
Principal Contact
Title
Phone No.
Fax No.
Est. Card $/Mo.
Avg. $/Sale
Type of Business
Sole Prop. Partnership Corp.
State of Incorporation
Age of Business
Date Acquired
President/Owner
% Ownership
S.S.# (Req.)
Residence Address
I Own I Rent, Since
Home Phone
Prev. Address (if less than 3 years)
D.O.B.
Co-Owner (If Applies)
% Owned
Since
Own Rent
Business Location...Type of Building
How Did You Find Total Merchant Services?
Commercial Residential Retail
Please Rank Your Credit
Prior Chapter 7, 11, 13?
Year
Excellent Fair Poor
Yes No
Type of Processing Equipment (required to process credit card transactions)
Secure Internet Processing Software PC/MAC Software Terminal
Terms: Lease Purchase Reprogram Existing