CREDIT CARD PROCESSING QUESTIONNAIRE

Date *

Corporate Name(INC/CORP/LLC) *

DBA Name(Same as on CC Receipt) *

Business Address *

City *

State*

Zip*

Tel *

Fax

Email*

Website

Employer Identification Number (EIN) *

State *

Date Business Started *

Owner Name *

SSN *

Owner Cellphone *

Home Address *

City *

State*

Zip*

Date Of Birth *

Driver LIC# *

State*

Bank Name

Routing(ABA)# *

Business Account Number *

Gross Yearly Sale (Credit/Debit) *

Yearly Total*

Average Purchase Ticket *

Highest Purchased Ticket*

Products or Services Sold *

Telephone Order % *

Business Type*

Agent/Referral Name

Agent/Client Notes

Please, provide a voided copy or a check bearing your company's name and your drivers license.

Attach the business voided check

Attach DL

$1997