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Name

Mobile Number

Email Address

Company/DBA

DBA Address:

DBA City, State, and Zip Code

Business Legal Name

Business Legal Address (City, State and Zip Code)

Business Federal Tax ID?

When did you open your business? (mm/yy)

What state is your business registered in?

What % of your sales are swiped/inserted?

What % of your sales are keyed in manually?

Do you take E-commerce payments?

Visa/Mastercard/Discover monthly sales volume?

What is the highest sale you will run?

How many high sales will you have per year?

American Express monthly sales volume?

American Express average ticket?

Signor's Name

Signor's Title

Signor's Ownership %?

Signor's Cell Phone Number?

Signor's Address including Street Number and Name, City, State, and Zip Code:

Signor's Date of Birth (mm/dd/yy)

Signor's SSN

What product/services do you provide?

What's your business type? (sole proprietorship, LLC, S-Corp?)

Business website address?

Who brought you to Certain Pay?