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We Process all Credit Card Types

1-888-996-CARD (2273)

Business Information:

Business Name/DBA:
Business Address:

City:

State:

ZIP Code:

Email Address:
Business Phone:
Business Fax:

Ownership Information:
(If less than 50% ownership please complete additional officer information.)

First Name:
Last Name:
Title:

Date of Birth:

Month: Day: Year:

Social Security # :	Phone:
% Ownership:

Home Address:

APT/Suite:

City:

State:

ZIP Code:

Additional Officer:

First Name:
Last Name:
Title:

Date of Birth:

Month: Day: Year:

Social Security # :	Phone:
% Ownership:

Home Address:

APT/Suite:

City:

State:

ZIP Code:

Additional Business Information:

Year Established:	Years: Months:
Length of Current Ownership
Services/Products:
Business Structure:
Federal Tax ID or SSN:
Current Bankcard Processor:

Have you or the business been party to any claims or lawsuits? (If so, please include an explanation in a cover letter.)
Have you or the business ever declared bankruptcy? (If so, please include an explanation in a cover letter.)

Estimated Average Credit Card Sale:	$ .00
Estimated Monthly Credit Card Volume:	$ .00

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National Transaction 11951 NW 37 Street Coral Springs FL 33065

Toll Free: 1-888-996-2273

Member service provider for US Bank Minneapolis Minnesota.

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