Pre-Application Form Business Information Business Name (Doing Business As) Location's Address (DBA Address) Address 1 Address 2 City State/Province Zip/Postal Code Country Contact Name * First Name Last Name Contact Email * Location's Phone Number (###) ### #### Business Type Description of merchandise, products, or services sold Legal/Corporate Phone Number (###) ### #### Years in Business Company Website (Optional) http:// Number of Locations Legal/Corporate Address Leave blank if same as DBA Address Address 1 Address 2 City State/Province Zip/Postal Code Country Estimated Annual Sales Volume (all sources) $ Estimated Annual Credit/Debit Volume $ Average Transaction Size monthly sales volume / amount of transactions $ Estimated Highest Possible Credit/Debit Sale $ Estimated % of Card-Not-Present Transactions Annually Do you do PIN Debit? Yes No Do you accept AMEX? Yes No How many people own 24% or more of this business? As required by The Patriot Act, please fill out the ownership information below by including any individuals with 24% or more ownership in the business. Once complete, please scroll to the bottom and submit info. 1 2 3 4 1. Legal Name of Owner/Partner First Name Last Name Title % Ownership Best Contact Phone Number (###) ### #### Best Contact Email Date of Birth MM DD YYYY Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country 2. Legal Name of Owner/Partner First Name Last Name Title % Ownership Best Contact Phone Number (###) ### #### Best Contact Email Date of Birth MM DD YYYY Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country 3. Legal Name of Owner/Partner First Name Last Name Title % Ownership Best Contact Phone Number (###) ### #### Best Contact Email Date of Birth MM DD YYYY Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country 4. Legal Name of Owner/Partner First Name Last Name Title % Ownership Best Contact Phone Number (###) ### #### Best Contact Email Date of Birth MM DD YYYY Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Thank you!