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OWNERSHIP INFORMATION
Owner 1 Name
Percent Owned
Owner 2 Name (Leave Blank If Sole Owner)
Percent Owned
Contact Name
Email Address
Best Phone Number To Reach you at
Legal Business Name
Doing Business As (DBA)
Business Street Address
City
State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Business Zip Code
Business Country
Business Phone Number
FAX Number
Date The Business Opened (Month/Day/Year)
About Your Business and Products Sold
Product, Service or Merchandise Sold
Type of Business? (Corporation, Partnership, Sole Ownership, etc.)
% Internet Orders
% Mail/Phone Order
% Face To Face (Swiped)
Estimated Average Credit Card Sale
>Estimated Credit Card Monthly Volume
Web Site Address
Have You Ever Accepted Credit Cards?	No Yes
If Yes, Do You Currently Accept Credit Cards?	No Yes
What Kind Of Equipment Or Online System Do You Want To Process Your Credit Card Orders (Note: Banks Now Require Transactions To Be Conducted Electronically-Paper processing Is No Longer Available)
Equipment Needs	Online Gateway/Virtual Terminal Terminal with Built in Printer Mobile Wireless Terminal Reprogram Existing Terminal
Business Owner Personal Information
Home Address
City
State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Home Phone Number
Rent or Own?
What is your credit rating?	Credit Rating Excellent Fair Poor Previous bankruptcy
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