Business Names(s)
|
|
Name of Account (Doing Business As) |
|
|
Exact Legal Name |
|
Physical Street Address
(If different from mailing address) |
City
County
-
Zip Code
|
|
Mailing/Billing Address |
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
E-mail
Web Site
|
|
Further Comments By Inspector |
|