Please fill out the following to the best of your ability.

*Please email a voided check to nhamdar@cardconnect.com

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* 1. Sales Code:

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* 3. Contact Name:

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* 4. Contact Email:

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* 5. Contact Phone Number:

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* 6. Tax ID (EIN):

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* 7. Legal Name of Business

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* 8. DBA Name:

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* 9. Business Start Date:

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* 10. Business Website:

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* 11. Business Phone Number:

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* 12. Business License Number:

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* 13. Business License State:

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* 14. Business Address:

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* 16. Owner First Name:

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* 17. Owner Last Name:

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* 18. Owner Email:

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* 19. Owner Email Address:

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* 20. Ownership Percentage

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* 21. Ownership D.O.B:

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* 22. Owner's Address:

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* 23. Owner's Driver's License Number:

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* 24. Owner's Driver's License State:

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* 25. Bank Name:

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* 28. Routing Number:

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* 29. Checking Number:

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* 30. Industry:

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* 31. Business Description:

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* 32. Average Monthly Volume:

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* 33. Average Ticket Amount:

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* 34. High Ticket Amount:

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* 35. When are cards charged?

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* 36. Services Generally Provided In:

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* 37. Refund Policy:

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* 38. Products/Services Are Delivered In:

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* 39. Cards Accepted:

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