| |
| Customer Information |
|
Business Legal Name
|
Is Your Business Seasonal
Yes
No |
|
Mailing/Billing Address
|
City
|
State
|
Zip Code (xxxxx)
|
|
Phone (xxx-xxx-xxxx)
|
DBA Fax (xxx-xxx-xxxx)
|
TAX ID # (xxxxxxxxx)
|
*Total # of Locations
|
| Customer "Doing Business As" Name |
|
*Customer “Doing Business As” Name
|
Business Start Date (MM/YYYY)
|
How Long At This Location
|
|
*Location Address
|
*City
|
*State
|
*Zip Code (xxxxx)
|
|
Phone (xxx-xxx-xxxx)
|
Primary Customer Contact
|
*Email Address
|
|
Business Information |
|
*Type of Ownership
|
Type of Business
|
Describe Merchandise Sold
|
|
Check Method of Advertising
Yellow Page Ads
Catalog
Direct Mail - Letter/Brochure
TV/Radio
Telephone/Marketing
Newspaper/magazines
Referral
Internet/Email |
|
Mail/Fax chargeback retrievals to
Outlet
Corporate |
Deliver statements to
Outlet
Corporate |
Deliver by
Mail
E-Mail |
|
Recon Solutions
Outlet
Chain |
American Express #
|
Discover Merchant #
|
|
Equipment Type
Rent
Purchase
Lease
Reprogram
Software Coding Only
|
|
Sales Deposit and Refund Policy |
|
% ANNUAL CREDIT CARD SALES GENERATED BY (TOTAL = 100%)
Mail/Phone
Internet
Card Swipe
Hand-Keyed Items Face-to-Face
|
|
PERCENTAGE OF CUSTOMER ORDERS DELIVERED IN (TOTAL = 100%)
0 Days 1-7 Days
8-14 Days 15-30 Days More Than 30 Days |
|
NUMBER OF DAYS TO PREPARE SHIPMENTS FOR DELIVERY TO CUSTOMER FROM DATE OF ORDER
|
|
ARE CUSTOMERS REQUIRED TO PROVIDE A DEPOSIT?
Yes
No |
|
IF A DEPOSIT IS REQUIRED, WHAT PERCENT OF THE TOTAL SALE IS REQUIRED? %
% of total sales |
|
MC/VISA SALES ARE DEPOSITED (CHECK ONE)
At Date Of Order
At Date Of Delivery
Other |
|
DO YOU HAVE A REFUND POLICY FOR YOUR MASTERCARD/VISA SALES?
Yes
No |
|
CHECK THE APPLICABLE REFUND POLICY
Exchange
Store Credit
MC/Visa Credit
Other |
|
IF MC/VISA CREDIT WITHIN HOW MANY DAYS DO YOU DEPOSIT CREDIT TRANSACTIONS?
0 -3 Days
4-7 Days
8-14 Days |
WHAT % OF PRODUCT/SERVICE DOES CUSTOMER RECEIVE AT TIME OF PURCHASE:
|
|
Owner/Officer
Information |
|
1. First Name
|
Last Name
|
Title
|
Percent of Ownership, %
|
|
*Residence Address
|
*City
|
*State
|
*Zip Code (xxxxx)
|
|
Home Phone (xxx-xxx-xxxx)
|
Date of Birth
|
Secial Security #
|
|
Driver's License #
|
Driver's License State
|
|
|
2. First Name
|
Last Name
|
Title
|
Percent of Ownership, %
|
|
*Residence Address
|
*City
|
*State
|
*Zip Code (xxxxx)
|
|
Home Phone (xxx-xxx-xxxx)
|
Date of Birth
|
Secial Security #
|
|
Driver's License #
|
Driver's License State
|
|
|
Company President
|
Company CFO
|
|
Credit Information |
|
Annual Visa/Mastercard Volume
|
Average Credit card Ticket
|
Total Sales
|
|
Mail or Telephone Order Sales (Complete if your sales are generated by mail, telephone or Internet orders, or if your product is not delivered at the point of sale.) |
|
Name of fulfillment house (if any)
|
If Fulfillment house, who owns inventory?
Customer
Fulfillment House |
Delivery time frame
|
|
Fulfillment house - street address
|
City
|
State
|
Zip Code (xxxxx)
|
|
Bank References |
|
Bank Name
|
Transit / Routing # (ABA #)
|
Account Number
|
|
Address
|
City
|
State
|
Zip Code (xxxxx)
|
|
If the customer has previously accepted credit cards, the last 3 months statements are required |
|
Current processing bank name
|
Reason for leaving current processor
|
Contact Person
|
|
City / State
|
Zip code
|
Phone
|
|
Have principals ever file bankruptcy?
Yes
No |
Chapter Filed
|
Date
|
|
HAVE ANY OF THE PRINCIPALS EVER MANAGED OR OWNED ANOTHER BUSINESS THAT ACCEPTED CREDIT CARDS?
Yes
No |
|
If yes, provide business name
|
City
|
State
|
|
SECOND PRINCIPAL
Yes
No |
|
If yes, provide business name
|
City
|
State
|
|
|
