Owner's Name:   Mr.   Ms.   Dr.

First name:* 

 Middle Initial:

Last name:* 

  

Type of Ownership:

Sole Proprietorship Partnership Public Corporation Private Corporation Non-Profit Corporation Limited-Liability Company Medical or Legal Corporation Associations/Estates and Trusts Tax Exempt Corporations (501c) Government (Federal/State/Local) International Organizations

Ownership Percentage: %

Is This a Home-Based Business? Yes No

Date of Birth (MM/DD/YY):

Contact Name, If Different:

/ /

Legal Name of Business:

Doing Business as (DBA), If Applicable:

Location of Business (No P.O. Boxes. If Home-Based, Enter Home Address):* 

Suite or Apartment # If Applicable

City:* 

State:* 

  Zip:* 

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Country:

United States     Other

If home address is the same as business address, click this box:

Home Address:

Suite or Apartment # If Applicable

City:

State:

Zip:

Country:

Select Your State Here Outside US Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana North Carolina North Dakota Nebraska Nevada New Hampshire New Jersey New Mexico New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington West Virginia Wisconsin Wyoming

Home Phone Number:

Business Phone Number:

( ) -

( ) -

Best Phone Number To Reach Applicant:

Fax Number:

( ) -

( ) -

Your Email Address:*

Your World Wide Web Address (If Applicable):

What Product or Service are you Selling? (i.e. I sell flowers):

Estimated Average Individual Credit Card Sale Amount: $

Estimated Total Monthly Credit Card Sales: $

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