JD Partners’ Pre-Application Form

Please note, this document is not an agreement for services.
To ensure timely processing, all fields must be completed.

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Business DBA

Company Name

DBA Phone

DBA Fax

DBA Address

City

State

Zip

Business Legal Name

Company Name

Corp Phone

Corp Fax

Corp Address

City

State

Zip

radio

Sole Proprietor

Corporation

Partnership

LLC

Date

Number of employees

State Business Formed in

Fed Tax I.D. Number

V/MC Average Charge Amt per Customer

V/MC Highest Charge Amt

V/MC Average Monthly Volume

Company Annual Revenue

Website Address

Free Text

Signor and each person controlling 25% or more of company must complete this section:

Office name

Officer Title

Home Address

City

State

Zip

mm/dd/yy

Home Phone

E-mail Address

Percentage of Ownership

Free Text

The following section pertains to the account to which your credit card funds will be deposited:

Contact Name

Bank Name

Bank Routing

Accounting

Address

City

State

Zip

JD Partners’ Pre-Application Form

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