PLEASE REMIT APPLICATION TO: (OVERNIGHT DELIVERY RECOMMENDED)Merchant Services Application and Agreement • June 7th, 2010 • Texas
Contract Type FiledJune 7th, 2010 JurisdictionMERCHANT INFORMATION DBA / OUTLET NAME CORPORATE NAME (IF DIFFERENT THAN DBA): PHYSICAL STREET ADDRESS: (NO P.O. BOXES) ADDRESS: CITY STATE ZIP CITY STATE ZIP PHONE: FAX: PHONE: FAX: CUSTOMER SERVICE PHONE NUMBER (REQUIRED FOR ALL MERCHANTS) WEB SITE ADDRESS: (REQUIRED FOR INTERNET MERCHANTS)