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:
Business Legal Name
Business DBA Name
Business Contact Name
Business Phone( ) Business Fax( )
Business Address
City State Zip
(Check if mailing address same as business address)
Business Mailing Address
City State Zip
Number of Locations
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 % Ownership
Home Address
City State Zip
Years at this address Home Phone( )
(Check if mailing address same as home address)
Home Mailing Address
City State Zip
Previous Address (if less than 2 years)
City State Zip
Social Security Number (No spaces or dashes)
Birth Date

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)


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