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Gordon Davis and Jamie Martin
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Please complete this form with the most up to date information about your business. We will use this information to create the agreement for your merchant account with Card Connect.

DBA CAR WASH INFORMATION
DBA Name*
DBA Car Wash Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is This Your Mailing Address
DBA Car Wash Phone Number*
Please enter a valid phone number.

CONTACT INFORMATION
Contact Name

First NameLast Name
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.

OWNER INFORMATION
Owner Name*

First NameLast Name
Ownership %*
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Social Security Number*
Date Of Birth*

MonthDayYear
Date
Home Address (No. P.O. Boxes)*

Street Address

Street Address Line 2

CityState

Zip Code
Is This Your Mailing Address
LEGAL BUSINESS INFORMATION

LEGAL ENTITY INFORMATION
Legal Name ( As Shown On Last Tax Return)*
Business Start Date*

MonthDayYear
Date
Ownership Type*
Phone Number*
Please enter a valid phone number.
Federal Tax ID*
Legal (Mailing) Address *

Street Address

Street Address Line 2

CityState

Zip Code

Bank Name*
Routing Number*
Account Number*
Comments (If Necessary)
Should be Empty:

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