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Business Name TAX ID*

Business NameFed TAX ID
Contact person/Manager *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Reporting Channel*

RestaurantGolfBarSpecialty RetailLodgingCollegeGYMADULTEventVendingStadium/ArenaLiquorOther
Payment Options (please select one)

CODNet 30Fintech
Please provide special notes if needed
Should be Empty:

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