Membership Application MEMBERSHIP DUES: $299 ONE TIME SIGN UP FEE OWNER’S NAME Phone Number HOME ADDRESS: CITY STATE ZIP CODE MERCHANT’S LEGAL BUSINESS NAME DBA (IF DIFFERENT THAN ABOVE) Phone Number FAX MAILING ADDRESS: CITY STATE ZIP CODE STREET ADDRESS (IF DIFFERENT THAN ABOVE) Email TYPE OF BUSINESS CORPORATION PARTNERSHIP SOLE PROPRIETORSHIP LLC Website FEDERAL ID NUMBER TAX BUSINESS NAME NAME FOR SS NUMBER SOCIAL SECURITY NUMBER UBI (Unified Business Identifier) EIN (Employer Identification Number) CATEGORY OF BUSINESS CHECK Number CREDIT CARD ACCOUNT NUMBER Expiration Date CVV Message I agree to the terms and conditions SUBMIT * See terms and conditions
