Merchant Application Form

BENEFICIAL OWNERSHIP INFORMATION

Please list all the beneficial owners that have 10% or more shares in the company. Note: For LLC/Corp, please list atleast 1 beneficial owner in this section even if same as control owner.

Owner Name:

Title:

DOB:

SSN:

Ownership Percentage:

Home Address:

City:

State:

Zip Code:

Phone:

Click to add another owner

Owner Name:

Title:

DOB:

SSN:

Ownership Percentage:

Home Address:

City:

State:

Zip Code:

Phone:

Click to add another owner

Owner Name:

Title:

DOB:

SSN:

Ownership Percentage:

Home Address:

City:

State:

Zip Code:

Phone:

Click to add another owner

Owner Name:

Title:

DOB:

SSN:

Ownership Percentage:

Home Address:

City:

State:

Zip Code:

Phone:

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