Countertop Terminal Sign-Up (page 1 of 2)

About You

Legal First Name

Legal Full Middle Name

Legal Last Name

Title

Date of Birth

Social Security Number

Ownership Percentage

Residence Address

City

State

Zip Code

About Your Business

Legal Name

Business DBA Name

Physical Street Address

City

State

Zip Code

Website Address

Goods Sold

Federal Tax ID (EIN)

DBA Phone

Corporate Email

Years Owned

Type of Ownership

Largest Single Transaction Amount Expected

Largest Monthly Volume Expected

Owners / Certification of Beneficial Owner(s) / Authorized Signer

Second Owner:

Third Owner:

Fourth Owner:

Second Owner

Legal First Name

Legal Full Middle Name

Legal Last Name

Title

Date of Birth

Social Security Number

Residence Address

City

State

Zip Code

Ownership Percentage

Third Owner

Legal First Name

Legal Full Middle Name

Legal Last Name

Title

Date of Birth

Social Security Number

Residence Address

City

State

Zip Code

Ownership Percentage

Fourth Owner

Legal First Name

Legal Full Middle Name

Legal Last Name

Title

Date of Birth

Social Security Number

Residence Address

City

State

Zip Code

Ownership Percentage