therapease

Agents Application - Therapease

Business Information
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Legal Name
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Referral Partner*
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Lead Source*
Type of Ownership
Doing-Business-As Name
Legal Business Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Premise Type
Length at Location
Business Phone
Federal Tax ID
Email
Description of Business Services
Length of Ownership
Website
Company
Personal Information
Legal Owner Name
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Time at current residence
Social Security
Date of Birth
MM slash DD slash YYYY
Personal Phone
Personal Email
Bank Information
Bank Name
Bank Routing Number
Bank Account Number
Credit Card Processing
Currently processing?
- Yes
- No
How are you taking cards?
- In person
- Online
- Over the phone
Average Monthly Volume
Average Ticket Amount
Highest Ticket Amount
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therapease

Agents Application - Therapease

Business Information

Personal Information

Bank Information

Credit Card Processing