Buena Vista - AltruPay

Legal Name of Business (as shown on tax return)*

DBA (Doing Business As Name)*

Federal Tax ID (EIN)*

State of Incorporation*

What Date was your Business Started?*

Entity Type*

Main Office Phone*

Owners Cell Phone*

Customer Service Email*

Legal Business Address*

Street Address Address Line 2 City State ZIP Code

Is Your DBA Address Different from your Legal Address?*

Yes

No

DBA Address*

Street Address Address Line 2 City State ZIP Code

Gross Annual Sales*

Average Monthly Credit Card Volume*

Average Monthly Check Volume*

Average Monthly Cash Volume*

Have you filed Bankruptcy in the last 3 years?*

Yes

No

Do you have any open Judgements or Liens?*

Yes

No

Owner #1*

First Last

Title*

Ownership %*

Owner Email*

Home Phone*

Cell Phone*

Date of Birth*

Social Security #*

Home Address*

Street Address Address Line 2 City State ZIP Code

Estimate Your Credit Score*

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Owner #2

Owner #2*

First Last

Title*

Ownership %*

Owner Email*

Home Phone*

Cell Phone*

Date of Birth*

Social Security #*

Home Address*

Street Address Address Line 2 City State ZIP Code

Estimate Your Credit Score*

Color Copy of a valid Driver's License of each owner*

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