EZ Application

General Information

Merchant Information Sheet (Confidential)

Scroll down to view all the fields to make sure you have all you information at your fingertips before you begin.

My Business is on: Oahu Maui Kauai Hawaii Molokai Lanai

Business Legal Name

Business DBA Name

Business Contact Name

Business Phone( ) Business Fax( )

Business Address

City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip

(Check if mailing address same as business address)

Business Mailing Address

City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip

Number of Locations 1 2 3 4 5 6 7 8 9 10

Dun & Bradstreet Number

Business Open Date

Ownership Begin Date

Federal Tax ID# (No spaces or dashes)

General Excise # (No spaces or dashes)

Web Address: http://

Email Address

Types of goods/services sold

Ownership Information

Owner/Partner/Member/Officer Name

Title

Type of Business Sole Prop Partnership Corporation LLC Non-profit Municipality % Ownership

Home Address

City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip

Years at this address Home Phone( )

(Check if mailing address same as home address)

Home Mailing Address

City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip

Previous Address (if less than 2 years)

City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip

Social Security Number (No spaces or dashes)

Birth Date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Credit Cards To Be Processed

Visa/MC AMEX (Current # ) Discover (Current # ) Diner's Club (Current # )

Bank Information

Bank Name Contact Phone ( ) Account #

Trade References

Business Name Contact Phone ( ) Account #

Business Name Contact Phone ( ) Account #

Equipment Type/Ownership

Choose one Own Rent Lease None

Equipment Type (if known)