CHECK SERVICES APPLICATION/SERVICE AGREEMENTCheck Services Application/Service Agreement • May 8th, 2014 • California
Contract Type FiledMay 8th, 2014 JurisdictionREGISTERED DBA: (“YOUR STORE”) AND/OR: LEGAL NAME: FEDERAL TAX ID#: BUSINESS STREET ADDRESS: BUSINESS TELEPHONE: CITY: STATE: ZIP: EMAIL ADDRESS: BUSINESS OWNERSHIP TYPE: □ SOLE PROPRIETOR □ PARTNERSHIP □ CORPORATION DATE OF BIRTH: BUSINESS OWNER/GUARANTOR: (“CONSUMER/PRINCIPAL”) RESIDENTIAL STREET ADDRESS: PRINCIPAL’S TELEPHONE: CITY: STATE: ZIP: SSN OF PRINCIPAL: FAX NUMBER: PRINCIPAL’S DRIVER’S LICENSE#: CURRENT MONTHLY CHECK SALES: $ TOTAL MONTHLY CHECK LOSSES: $ AVERAGE CHECK SALE: $ AVERAGE RETURNED CHECK: $ PRODUCTS OR SERVICES OF APPLICANT: NUMBER OF LOCATIONS APPLIED FOR: CURRENT CHECK SERVICE: CURRENT RATE: POINT-OF-SALE EQUIPMENT TYPE: CHECK IMAGER/READER: PRINTER TYPE: