Business Information
Legal Name
DBA
Business Address
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Federal Tax ID
Confirm Tax ID
State of Formation
Entity Type
Sole Prop
Private Corp
LLC
Partnership
Public Corporation
Government
Non Profit
C Corp
S Corp
PA/PC
Tax Exempt
Business Profile
Start Date
Years In Business
Months In Business
Business Phone
Contact First Name
Website
Email
# Locations
Location Accepts CC?
N/A
Yes
No
VISA/MC/DISCOVER Monthly Volume
Amex Monthly Volume
Average Ticket
High Ticket
Customer Sales Breakdown (Must Equal 100%)
Swiped
Keyed
Internet
Moto
Owner/Principle Information
First Name
Last Name
Title
President
Vice President
Treasurer
Owner
CEO
Secretary
Director
Others
Mobile
Date of Birth
Social Security Number
Confirm SSN
Home Address
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
DL Number
DL State
Expiry Date
Email
Ownership
Management Responsibility
N/A
Yes
No
Personal Bankruptcy
Business Bankruptcy
Never Filed
Banking Information
Bank Name
Routing #
ACCOUNT #
CONFIRM ACCOUNT #
Fulfillment Information
Where is your product stored?
N/A
DBA Address
Corporate Address
Off Site
Do you use 3rd party fulfillment?
N/A
Yes
No
Fulfillment Company Name
Fulfillment Company Phone
Do You own inventory?
N/A
Yes
No
When is your customer charged?
At Time of Order
Upon Shipment
How soon do you deliver?
1-7 Days
8-14 Days
14+ Days
Do you provide customer service?
N/A
Yes
No
Advertising Methods
Refund Policy
Supporting Documentation
Please Upload 3 Months of Business Bank Statement
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