Brian Miller
National Card Payments
brian@kbcardprocessing.com

Direct: 8016990486

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Processing

1. Business Name

"Doing business as" Name ?

Legal Name of Business ?

2. Business Physical Address ?

Street

City

State

Zip Code

3. Business Legal Address ?

Click here if same as physical address

Street

City

State

Zip Code

4. Mailing Address

Click here if same as physical address

Street

City

State

Zip Code

5. Other Business Info

Business Phone #

Customer Service Phone # (click here if same as business phone #) ?

Website Address

Year Business Established

Federal Tax ID # (EIN) ?

Business Entity Type

6. Financial Information

Deposit Bank Name ?

Bank 9 Digit Routing Number ?

Checking Account Number

7. Account Contact Person

Name ?

Email Address

8. Application Signer Information

Click here if address is the same as owner #1

Full Name of Signer

Social Security Number

Percentage of Ownership

Date of Birth (mm/dd/yyyy)

Cell Phone Number

Street

City

State

Zip Code

Are there any other owners with 25% or more ownership? Yes No

Owner #1

Full Name of Signer

Social Security Number

Percentage of Ownership

Date of Birth (mm/dd/yyyy)

Cell Phone Number

Street

City

State

Zip Code

Are there any other owners with 25% or more ownership? Yes No

9. Signer's U.S. State Drivers License, or State ID, or Passport

Document ID #

Issue Date (mm/dd/yyyy)

Date of Expiration (mm/dd/yyyy)

State where document was issued

10. Processing Information

Average Credit Card Transaction Amount (in dollars)

High Single Credit Card Transaction Amount (in dollars)

Number of Times Per Year High Single Transaction Amount Occurs

Average Monthly Credit Card Sales Volume (in dollars)

Total Company Annual Sales (in dollars)

What Product and/or Services Are Being Sold?

How Many Days Until Product and/or Services is delivered?

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Processing

Owner #1

Thank you!