This Member Application and Service Agreement (“Application”) form may be completed using your computer. In order to use the fillable features, please note the following:Member Application and Service Agreement • November 24th, 2017 • Georgia
Check all that apply: PPD CCD WEB TEL BOC ARC POP RCK Check 21 Check Guarantee ISO/Agent Name: COMPANY INFO BUSINESS DATA Legal Name: DBA: Contact Person: Phone Number: Fax Number: Website URL: E‐Mail: Business Address: City: State: Zip: Business Start Date: Business Type: Goods / Services: Average Ticket: High Ticket: Annual Check Volume: Total Sales Volume: Business Tax ID: Corporate Structure:Non‐Profit Sole Proprietorship Private Corp LLC Public Corp Partnership OWNER INFORMATION (for beneficial owners of 25% or more) OWNER INFORMATION (for beneficial owners of 25% or more) Full Name: Percentage Ownership: Home Address: City: State: Zip: Title: Social Security #: Driver’s License #: State: Phone Number: Fax Number: Full Name: Percentage Ownership: Home Address: City: State: Zip: Title: Social Security #: Driver’s License #: State: Phone Number: Fax Number: OWNER INFORMATION (for beneficial owners of 25% or more) OWNER INFORMATION (for beneficial owners of 25% or more) Full Name:
