Merchant Application Business Information Legal Name of Business: DBA Name: Date of Business Established: Taxpayer Indentification Number: Business Phone Number: Type of Business: Liquor storeGrocery StoreConvenience StoreHotelOther BUSINESS PHYSICAL ADDRESS Address (NO P.O. Boxes): Unit#: City: State: Zip: CORPORATE ADDRESS (IF DIFFERENT THAN PHYSICAL ADDRESS) Same as primary Address (NO P.O. Boxes): Unit#: City: State: Zip: Business E-mail (For notices and all other communication): Business website Address if applicable: Principal Information List name one Principal owner position held with company Last Name: First Name: Middle Name: Title: Ownership Percentage: Date of Birth: Social Security Number: Home Phone: PRINCIPLE HOME ADDRESS Address: Unit#: City: State: Zip: Driver's License Number (Attach copy to Application): State issuing Driver's License: License Expiration Date: Owner's Email Address: Cell Phone Number: Attachment Required Driver's License: YES Voided Check or Bank Letter: YES FSN No. (If you process EBT/Food Stamp): YES Banking Information Name of Bank or Financial Institution: Address: Contact Name & Phone: Business Checking account Number: Business Checking routing Number: Credit Card Terminal: Encryption: N/AWF 350 (Nashville)WF 350 (Buypass) Gas Station POS: N/AGilbarcoRuby CommanderRuby w/ MicronodePetrotechPOS Installation Date: Other Fleet Cards: Site ID #: Pricing: Member Operated Location: N/AYesNo Other Notes:
