BUSINESS INFO

Legal Business Name:
DBA/Outlet Name:
Date of Incorporation (MM/YY):
Store Address:
Phone Number:
Email:
Fax Number: (Optional)

Store Number:
Number of Employees:
Owner Name:
Owner Contact Number:

Drivers License #:
Date of Birth (MM/DD/YY):
Address on License (#, Street, City, State,ZIP):
VISA / Mastercard (Provide only first 4 and last 4 digits):
VOID Cheque:
Statement Preference: ---EmailPrint



Number of Wired Terminals Required:
Number of Wireless Terminals Required for Catering/Deliveries:

ACCOUNT INFO

(Optional)

Debit Cash Back: ---YesNo



Electronic Funds Transfer Platform Setup (used for Salary and Supplier Payments): ---YesNo



Estimated Annual Sales (All Cards): $
Estimated Annual Interac Sales: $
Estimated Annual Visa Sales: $
Estimated Annual M/C Sales: $