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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



      Upload Files

        Signage Page

        Voided Check

        Upload ID