Merchant Application

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Retailer Information

Legal Business Name

Business Name or DBA

Tax ID Number

Year Established

Website URL

Industry

Primary Industry

Current Purchasing Options

How did you hear about us?

Comments

Location Information

Location Name

Headquarters?

Country

Phone Number

Street Address

Unit

City

State

Zip Code

Primary Contact Person at Location

Position

Lease Contact Information

Store Email Address

Funding Email Address

Owner Information

First Name

Last Name

Work Phone

Mobile Phone

Email

User Account Creation

First Name

Last Name

Email Address

Phone Number

Username

Password

Password Confirmation

Bank Information

Bank Account Number

Institution Number

Transit Number

Routing Number

Bank Name