Name of Office (DBA “Doing Business As”)

Legal Name

Business Type

Business Location Address

Business Location City

Business Location State

Business Location Zip

Contact First Name

Contact Last Name

Contact Email

Contact Phone (No Dashes)

Secondary Phone (No Dashes)

Website

Business Open Date

Merchant Category Code

Type of Goods/Service Sold

Federal Tax ID # (No Dashes)

Application Signor Name (must have financial signing authority for the business)

Example: John Doe

Signor Title

Signor Date of Birth

Signor SSN (No Dashes)

Signor Email

Signor Phone Number

Signor Home Address (Street)

Signor Home City

Signor Home State

Signor Home Zip

Does Signor have 25% or more ownership?

Signor Ownership Percentage (if any)

Example: 60, 100

According to FINCEN regulations, all business owners with a 25% or more share in the business must be documented below. Besides the above Business Owner, how many business owners have 25% or more share? Select zero (0) if you are the sole owner of the business.

Beneficial Owner Name 1

Example: John Doe

Beneficial Owner Title 1

Beneficial Owner Date of Birth 1

Social Security Number 1 (No Dashes)

Beneficial Owner Email 1

Beneficial Owner Phone 1

Beneficial Ownership Percentage 1

Example: 60, 100

Beneficial Owner Home Address 1

Beneficial Owner Home City 1

Beneficial Owner Home State 1

Beneficial Owner Home Zip 1

Beneficial Owner Name 2

Example: John Doe

Beneficial Owner Title 2

Beneficial Owner Date of Birth 2

Social Security Number 2 (No Dashes)

Beneficial Owner Email 2

Beneficial Owner Phone 2

Beneficial Ownership Percentage 2

Example: 60, 100

Beneficial Owner Home Address 2

Beneficial Owner Home City 2

Beneficial Owner Home State 2

Beneficial Owner Home Zip 2

Beneficial Owner Name 3

Example: John Doe

Beneficial Owner Title 3

Beneficial Owner Date of Birth 3

Social Security Number 3 (No Dashes)

Beneficial Owner Email 3

Beneficial Owner Phone 3

Beneficial Ownership Percentage 3

Example: 60, 100

Beneficial Owner Home Address 3

Beneficial Owner Home City 3

Beneficial Owner Home State 3

Beneficial Owner Home Zip 3

Beneficial Owner Name 4

Example: John Doe

Beneficial Owner Title 4

Beneficial Owner Date of Birth 4

Social Security Number 4 (No Dashes)

Beneficial Owner Email 4

Beneficial Owner Phone 4

Beneficial Ownership Percentage 4

Example: 60, 100

Beneficial Owner Home Address 4

Beneficial Owner Home City 4

Beneficial Owner Home State 4

Beneficial Owner Home Zip 4

Annual Volume

Average Ticket

Highest Ticket

Bank Name

Routing #

Bank Account #

Void Check or Bank Verification Letter

Additional Attachment

If the business has no individual with more than 25% ownership, a letter on company letterhead is required stating that fact and that the signor has the ability to sign. This letter must be dated and signed.