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Address 2
City
State/Zone
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Postal Code
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Website Address
Country of Origin
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Albania
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Albania
Algeria
Austria
Bahrain
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Egypt
Estonia
Faroe Islands
Finland
France
France, Metropolitan
Germany
Gibraltar
Greece
Guernsey
Hungary
Iceland
Iraq
Ireland
Islamic Republic of Iran
Isle of Man
Israel
Italy
Jersey
Jordan
Kuwait
Latvia
Lebanon
Liberia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malaysia
Malta
Mexico
Moldova, Republic of
Monaco
Montenegro
Morocco
Netherlands
Norway
Oman
Palestine Authority
Poland
Portugal
Qatar
Republic of Serbia
Romania
San Marino
Saudi Arabia
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Syrian Arab Republic
Tunisia
Turkey
United Arab Emirates
United Kingdom (Great Britain)
United States
Yemen
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Roma
Rovigo
Salerno
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Savona
Sicily
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Siracusa
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Taranto
Teramo
Terni
Torino
Trapani
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Trento
Treviso
Trieste
Tuscany
Udine
Umbria
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Veneto
Venezia
Verbano-Cusio-Ossola
Vercelli
Verona
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Viterbo
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Albania
Algeria
Austria
Bahrain
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Egypt
Estonia
Faroe Islands
Finland
France
France, Metropolitan
Germany
Gibraltar
Greece
Guernsey
Hungary
Iceland
Iraq
Ireland
Islamic Republic of Iran
Isle of Man
Israel
Italy
Jersey
Jordan
Kuwait
Latvia
Lebanon
Liberia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malaysia
Malta
Mexico
Moldova, Republic of
Monaco
Montenegro
Morocco
Netherlands
Norway
Oman
Palestine Authority
Poland
Portugal
Qatar
Republic of Serbia
Romania
San Marino
Saudi Arabia
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Syrian Arab Republic
Tunisia
Turkey
United Arab Emirates
United Kingdom (Great Britain)
United States
Yemen
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EBT Services
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Percent
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Date of Birth
SSN
Telephone
Current Street Address
Ownership Percentage
Yrs. on Address
Email
City
State
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Abruzzo
Agrigento
Alessandria
Ancona
Aosta
Aosta Valley
Apulia
Arezzo
Ascoli Piceno
Asti
Avellino
Bari
Basilicata
Belluno
Benevento
Bergamo
Biella
Bologna
Bolzano
Brescia
Brindisi
Cagliari
Calabria
Caltanissetta
Campania
Campobasso
Carbonia-Iglesias
Caserta
Catania
Catanzaro
Chieti
Como
Cosenza
Cremona
Crotone
Cuneo
Emilia-Romagna
Enna
Ferrara
Firenze
Foggia
Forli-Cesena
Friuli Venezia Giulia
Frosinone
Genova
Gorizia
Grosseto
Imperia
Isernia
L'Aquila
La Spezia
Latina
Lazio
Lecce
Lecco
Liguria
Livorno
Lodi
Lombardy
Lucca
Macerata
Mantova
Marche
Massa-Carrara
Matera
Medio Campidano
Messina
Milano
Modena
Molise
Napoli
Novara
Nuoro
Ogliastra
Olbia-Tempio
Oristano
Padova
Palermo
Parma
Pavia
Perugia
Pesaro e Urbino
Pescara
Piacenza
Piedmont
Pisa
Pistoia
Pordenone
Potenza
Prato
Ragusa
Ravenna
Reggio Calabria
Reggio Emilia
Rieti
Rimini
Roma
Rovigo
Salerno
Sardinia
Sassari
Savona
Sicily
Siena
Siracusa
Sondrio
Taranto
Teramo
Terni
Torino
Trapani
Trentino-South Tyrol
Trento
Treviso
Trieste
Tuscany
Udine
Umbria
Varese
Veneto
Venezia
Verbano-Cusio-Ossola
Vercelli
Verona
Vibo Valentia
Vicenza
Viterbo
ZIP Code
Previous Street Address (if current is under 2 years)
Yrs. on Address
City
State
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Abruzzo
Agrigento
Alessandria
Ancona
Aosta
Aosta Valley
Apulia
Arezzo
Ascoli Piceno
Asti
Avellino
Bari
Basilicata
Belluno
Benevento
Bergamo
Biella
Bologna
Bolzano
Brescia
Brindisi
Cagliari
Calabria
Caltanissetta
Campania
Campobasso
Carbonia-Iglesias
Caserta
Catania
Catanzaro
Chieti
Como
Cosenza
Cremona
Crotone
Cuneo
Emilia-Romagna
Enna
Ferrara
Firenze
Foggia
Forli-Cesena
Friuli Venezia Giulia
Frosinone
Genova
Gorizia
Grosseto
Imperia
Isernia
L'Aquila
La Spezia
Latina
Lazio
Lecce
Lecco
Liguria
Livorno
Lodi
Lombardy
Lucca
Macerata
Mantova
Marche
Massa-Carrara
Matera
Medio Campidano
Messina
Milano
Modena
Molise
Napoli
Novara
Nuoro
Ogliastra
Olbia-Tempio
Oristano
Padova
Palermo
Parma
Pavia
Perugia
Pesaro e Urbino
Pescara
Piacenza
Piedmont
Pisa
Pistoia
Pordenone
Potenza
Prato
Ragusa
Ravenna
Reggio Calabria
Reggio Emilia
Rieti
Rimini
Roma
Rovigo
Salerno
Sardinia
Sassari
Savona
Sicily
Siena
Siracusa
Sondrio
Taranto
Teramo
Terni
Torino
Trapani
Trentino-South Tyrol
Trento
Treviso
Trieste
Tuscany
Udine
Umbria
Varese
Veneto
Venezia
Verbano-Cusio-Ossola
Vercelli
Verona
Vibo Valentia
Vicenza
Viterbo
ZIP Code
Processing information
Previous processor
Refund Policy (none, 30days, exchange only, etc.)
Terminal(s) Brand & Model
Terminal(s)
--- select option ---
Own
Purchase
Rent
Quantity
Cost Each
Statement Delivery Preference
--- select option ---
Email
Company Address
Charge Back Delivery Preference
--- select option ---
Email
Company Address
Processing Information
Annual Volume ($)
Average Ticket ($)
Highest Ticket ($)
Projected Monthly Sales
Projected Yearly Sales
Highest Ticket Frequency
According to the Merchant Agreement for Transaction Services, it is necessary for Merchant to provide its banking information to facilitate billing and payments. The Merchant must inform the Processor of any changes to its banking details and accounts. The Processor will not be liable for any funds incorrectly transferred due to a change in banking information or errors that directly resulted from the information provided by Merchant. Merchant authorizes the Processor to debit from the Merchant’s bank account all monthly payments and other amounts owed to the Processor related to the Transaction Services. This authorization shall remain in effect after termination of the authorization shall remain in effect after termination of the Agreement and for as long as Merchant owes any amounts to the Processor. Merchant agrees that the Processor will not be liable for any loss or damage incurred as a result of anything done or not done according to this authorization. If the account is transferred to another branch or the account is closed, and an account is opened at another bank, this authorization shall have the same force and effect as if it originally was directed to that branch or bank. The undersigned Guarantors acknowledge and agree to be bound by all the terms and conditions of this Agreement and unconditionally guarantee the performance of this Agreement. By signing below, Merchant (I) represents that the information provided by Merchant in this Agreement is accurate, complete, and not misleading; (II) acknowledges that Merchant has read and understands this Agreement and Operating Procedures and agrees to be bound by their terms; and (III) authorizes the Processor and its agents to credit and debit the Designated Automatic Funds Transfer Account in accordance with this Agreement.
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I attest to the satement above and that I have read and agree to the Service Agreement
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