Merchant Application and Agreement - Merchant ….pdf

Merchant Application and Agreement If you make any corrections, you MUST initial each change. THIS SECTION IS FOR INTERNAL USE ONLY Rev. NAPSTAND 01/2012 Application ID: Sales Rep: Rep Fax: Rep Phone: 1. Merchant Business (Federal regulations require us to collect and retain information verifying a merchant’s identity.) “Doing Business As”(DBA) Information Merchant DBA Name Date Business Started (MM/YYYY) DBA Street Address (No PO Box or Paid Mail Box) Telephone # City State Zip Code Fax # Name of Primary Contact Merchant DBA Email Address Legal Information (If you are an Individual/Sole Proprietor, fill in this section with your personal information) Merchant Legal Name State of Formation Federal Tax ID/EIN (sole prop use SSN) Complete this section if different from DBA Information. Legal Street Address Telephone # City State Zip Code Fax # Legal Email Address Business and IRS Information (Please check the type of business and how it is taxed) LLC taxed as S Corporation C Corporation Partnership Disregarded Entity Individual/Sole Proprietor A Disregarded Entity is a business that is separate from its ow ner for legal purposes but the owner chooses to “disregard” that separation for federal e tax pu rposes. If an individual owns a Disregarded Entity, it is treated as a sole proprietor. If another legal entity owns it, it is treated as a branc h or division of the owner. Partnership Private Corporation or Public Corporation taxed as S Corporation C Corporation Government Agency or Non-Profit check if Exempt from IRS backup withholding Non-panies need to subm it form 501C and, if ex empt from sales tax, should also s ubmit their state tax exempt certifi cate. 2. Merchant Profile Is your business home-based? Yes No Has business ever been in bankruptcy? Yes No If “Yes” above, where is the inventory located? What is your type of business? Re