BUSINESS NAME Business Name DBA Street Address Address Line 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Phone Fax Complete Information Below if Mailing Address is Different Mailing Name DBA Street Address Address Line 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Phone Fax Merchant Profile Type of Ownership  Sole Proprietor   Partnership  Corporation  Other   Type of Goods or Service Sold No Years in Business Has this Business or Any Associated Principal Been Terminated as a Visa/Matercard Merchant?  Yes  No Visa/MasterCard Information Merchant Type  Retail Outlet  Restaurant/Food  Home Business, Trade Fairs, Outside Sales/Service, Other  Mail Order/Telephone Order Only Swiped/Keyed  Percent of Credit Cards Swiped  Percent of Credit Cards Keyed If You Have Indicated that 20% or More of your Transactions are Keyed - Complete This Section Percent Telephone Orders   Percent Mail/Fax Orders   Percent Manual Imprint   Methods of Marketing  Newspaper/Magazine  Internet  TV/Radio  Direct Mail  Telemarketing What Services do You Already Have Do You Currently Accept Visa/MasterCard? If Yes, you must submit 3 most current statements Yes — Mercant#   No  Do You Currently Accept American Express?  Yes — Merchant#   No Do You Currently Accept Discover?  Yes — Merchant#   No Do You Currently Accept Diners?  Yes — Merchant#   No Do You Currently Accept JCB?  Yes — Merchant#   No What Extra Services do You Want (Visa/MasterCard Included) Amex   Discover   Diners   JCB   INTERNET Section Will You Be Doing Secure Transactions on the INTERNET?  Yes  No Do You have a Web Site?  Yes — URL   No Email Address Enter Your Address Here  Would You Like to be Contacted by Our Internet Department about a Web Site or Hosting?  Yes  No Owners and Officers 1st Owner or Officer Name Title Street Address Address Line 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Home Phone Do you Own/Rent your Home  Own  Rent % Equity Social Security Number 2nd Owner or Officer Name Title Street Address Address Line 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Home Phone Do you Own/Rent your Home  Own  Rent % Equity Social Security Number