Fill out the following online form Business Information Client's Business Name (Doing Business As) (required) Business Address (required) City (required) State(required) zip(required) Location Phone #(required) Location Fax # Business Email Address(required) Business Website Address(required) Customer Service Phone #(required) Customer Service Email Address(required) Corporate Information Client's Corporate/Legal Name (Use Also For Head quarter's information) Billing Address (If Different Then Location Address) City State zip Contact Name Contact Fax# / Email Address: Contact Phone # Send Retrieval Requests to: Business LocationCorp/Legal Location Send Merchant Monthly Statement to: Business LocationCorp/Legal Location Federal Tax ID # (as it appears on your income tax return) ADDITIONAL CREDIT / SITE SURVEY INFORMATION - ALL MERCHANTS Zone Business DistrictIndustrialResidential Location MallOfficeHomeShopping AreaApartmentIsolatedDoor-to-DoorFlea MarketOther How many employees: Remaining Floors Occupied by: ResidentialCommercialCombinationNone Approximate Square Footage: 0-250251-500501-20002001 plus Are customers required to leave a deposit? YesNo If yes, % of deposit required: Return Policy: Full RefundExchange OnlyNone OWNERS / PARTNERS / OFFICERS Name (First, MI, Last) (required): % Ownership (First, MI, Last) (required): Title (First, MI, Last) (required): Home Address (required): City (required): State (required): Zip (required): Telephone (required): D.O.B. (required): SETTLEMENT INFORMATION Financial Data Deposit Bank (required): Transit / ABA # (required): Deposit Account # (required): TRANSACTION INFORMATION Gross YEARLY Sales Volume(Cash + Credit + Debit + Check) (required): Average YEARLY MC/Visa Volume (required): Average YEARLY Discover Network-PayPal Volume (required): Average YEARLY American Express OptBlue Volume (required): Avg. MC/Visa/Discover Network-PayPal Tickets (Estimate if Never Processed in the Past) (required) Avg. American Express OptBlue Ticket (Estimate if Never Processed in the Past) (required) Highest Ticket Amount (required) Where is sale Transacted? (The following must add up to 100%) Store Front/Swiped (required) Internet (required) Mail Order (required) Telephone Order (required) Signature Terms of Agreements Signature (required) Title (required) Print Name of Signer (required) Date (required) Personal Guarantee View Statement Signature (required) Print Name (required) Date (required)