Intake Form – The Gatlic Group

Merchants Legal Name*
First Last
Corporate Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
DBA*
DBA Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Email*
Do You Have a Great Website?*
- Yes
- No
Website Address
Business Data
Federal Tax ID #*
Type of Ownership*
Untitled*
Date Business Started**
Month
Day
Year
Types of goods and services sold*
Owners Name*
First Last
Owners Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Owners Phone*
Owners DOB**
Month
Day
Year
First 6 Digits of Owners SS#*
Prior Bankruptcies ?*
- Yes
- No
Monthly Card Sales*
Average Ticket*
Highest Ticket*
Deposit Routing #*
Agent that referred you
Type of equipment
Comments
This field is for validation purposes and should be left unchanged.

Business Data