Merchant Application - Luciano

Merchant Application v2

Type of Business Entity

Business Legal Name:

State of Incorporation:

Business DBA Name:

EIN #:

Physical Street Address:

City

State

Zip Code

Business Phone #:

Cell Phone #:

Business Type: (Description)

Business Start Date:

Funding Amount Requested: ($)

Gross Annual Sales: ($)

Use of Proceeds:

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