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Merchant Application - Roger
Merchant Application v2
Business Information
Type of Business Entity
*
Corporation
Limited Liability Company
Partnership
Limited Partnership
Limited Liability Partnership
Sole Proprietor
Business Legal Name:
*
State of Incorporation:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Business DBA Name:
*
EIN #:
*
Business Address
Physical Street Address:
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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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