Primary Contact
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
Will also serve as a Primary Login
Legal Business Name
*
Exactly as found on formal registration
Main Business Phone
*
-
Area Code
Phone Number
Main Business Email
*
example@example.com
Business Website
*
If Multiple, list the Primary
Business Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Formation Type
*
Incorporated
Limited Liability Company
Partnership
Sole Proprietorship
Other
Years in Operation
*
Legal Time in Business
Federal Tax ID
*
EIN - 9 digits
Voided Check
Browse Files
Funds will be ACH'd if Bank Account Info is on file
Cancel
of
Legal Proof of Business
Browse Files
Record of Registration with State Entity
Cancel
of
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Owner/Corporate Officer Information
Full Name
First Name
Last Name
Title
Length in Position/Ownership
/
Month
/
Day
Year
Start Date of Ownership/Position
Ownership Percentage
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Date of Birth
/
Month
/
Day
Year
Date
Social Security Number
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Business Information
Number of Locations/Stores
Average Monthly Gross Revenue
Average Ticket Price of Equipment
Type of Equipment Sold
Complete
Should be Empty: