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Merchant Profile

General Information
Must Match IRS Tax Filing
Corporate Address
Mailing Address (If Different Than Above)
Contact Name
Contact Business Email
Date Started
Business Structure

Owner

Name
Email
Home Address
Date of Birth
Additional Owners?
Additional Owners? (2+)

Owner 3

Name
Email
Home Address
Date of Birth
Additional Owners? (3+)

Owner 4

Name
Email
Home Address
Date of Birth

Nature of Business

Business Type
Do you accept EBT?
Credit Card Statement Provided?
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