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Business Names(s)

Name of Account (Doing Business As)
Exact Legal Name
Physical Street Address
(If different from mailing address)
other
         
City
County

-Zip Code
Mailing/Billing Address
other
         
City
County

-Zip Code
Business Contact Info ()- x Phone
()- x Cell Phone
()- x Fax
()- x Pager
()- x Other Phone

E-mail
Web Site

Federal Tax I.D. #
Merchandise/Services Sold mike see 1

Merchant Profile

Type of Ownership
Length of ownership Years Months

Visa/Mastercard Information

Do you currently Visa/Mastercard?
Current / Previous Bank Card Processor
Reason for Leaving
Average Ticket $
High Ticket $
Average Monthly Volume $
High Monthly Volume$
Card Swiped %
Manually Keyed %
Mail Order %
Telephone Order %

Merchant Site Report

Merchant Location Retail Location with Store Front
Office Building
Residence
Other
Area Zoning Commercial
Industrial
Residential
Square Footage 0-250
251-500
501-2000
2001+
Nearest major cross streets or highways
Merchant owns the business premises? Yes
No - If no enter:
Whom does Merchant lease from?:
Name:
Phone: ()- x
Address:
other
         
City
County

-Zip Code

E-mail
Web Site

Further Comments By Inspector