CONFIDENTIAL MERCHANT INFORMATION SHEET

ATTN: Troy Grubbs| Phone: (678) 255-4133

Email: troy.grubbs@fiserv.com

Business Legal Name: ____________________________________________________________________________

D/B/A Name: _______ ___________________________________________________________________________

Physical Street Address of Business (NO PO Boxes): ____________________________________________________

City: _____________________________________________________ State: ________ Zip: ______________

Phone #: _____________________________________ Fax #: _________________________________________

E-mail Address: ________________________________________________________________________________

Web site: www.________________________________________________________________________________

Date Business Began: M ________ / Y __________ Number of Employees: _______________________

Product/Services Sold:

Circle One: Sole Ownership Partnership Public Corporation Private Corporation Non-Profit LLC

Annual Gross Sales: $ __________ Annual MC/Visa Sales: $ ________________ Average Ticket: $ _______

Federal Tax ID #: ___________________________________________________________________________

Bank Name: __ ______________________________________________________________________________

Routing#: ______________________________ Account #: _______________________________________

Owner / Signer Information:

Owner/Officer's Name: _______________________________________ Title: ____________________________

Home Address: ___________________________________________________________________________

City: _____________________________________ State: ________________ _ Zip: _____________________

Home Phone #: _________________ Social Security #: _________________ DOB: ____________________

*Personal Information is required for Identity Purposes Only* Credit Inquiries Do Not Show up on your Credit Report*