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Legal Name

DBA Name

Legal Business Address

City, State, Zip/Postal Code

DBA Address

DBA City, State, Zip/Postal Code

Type Of Ownership

Length At Location

Premise Type

Business Phone Number

Website

Contact Email Address

Return & Refund Policies

Description of Products/Services

OWNER INFORMATION

% Of Business Owned

Date Of Birth

Phone Number

Home Address

City, State, Zip/Postal Code

Length At Current Residence

Transaction Information Currently Processing?

Yes

No

How are you taking cards?

All Previous Processors (if any)

Average Monthly Sales Volume

Average Transaction Amount

Highest Transaction Amount

777 Brickell Avenue

Suite 500

Miami, Fl 33137

305-306-8874