Merchant Information Form BUSINESS INFORMATION Name of Business Corporate/Billing Address Location Address City State Zip City State Zip Phone Federal Tax ID Phone Fax Name as appears on tax return I am Foreign National Contact Name NOTE: Failure to provide accurate information may result in a withholding of merchant funding per IRS Regulations (See Part IV, Section A.4 of your Program Guide for further information.) Web Address Email Address Customer Service # MERCHANT INFORMATION RetailServiceHomeMO/TOInternet Describe business detail Type of Corporation State of Incorporation PRINCIPAL INDIVIDUAL #1 % Ownership Last Name First Name MI Title Residence Address City State Zip Home Phone DOB Drivers License Lic State PRINCIPAL INDIVIDUAL #2 % Ownership Last Name First Name MI Title Residence Address City State Zip Home Phone DOB Drivers License Lic State Δ