Owner Name Percentage of Ownership Corporate Name DBA Name DBA Address Mailing Address Phone Email * Date Business Established What type of entity? If LLC please enter which type? Home Address Mobile Phone Date of Birth Transaction Detail Average Sale, Total Monthly, Largest Sale Transaction Detail Card Present %, Card Not Present %, Internet % ( must = 100%) What types of goods do you sell? Second Owner 2nd Owner Name Percentage of Ownership Home Address Email * Phone Date of Birth
