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GENERAL INFORMATION:
Your Email Address:

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

OWNER/PRINCIPAL INFORMATION:


President/Owner

Title

% Ownership

S.S.# (Req.)

Residence Address

City/State/Zip

I Own I Rent, Since

Home Phone

Prev. Address (if less than 3 years)

D.O.B.

Co-Owner (If Applies)

Title

% Owned

S.S.# (Req.)

Residence Address

City/State/Zip

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



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