FIRST DATA COMMERCIAL SERVICES
Date: __________________
__________________________________MERCHANT INFORMATION____________________________
Your Business Legal Name:__________________________________________________________________
DBA / Outlet Name:________________________________________________________________________
Contact: _____________________________________
Business Address ( No P.O. Box):_____________________________________________________________
Business Phone #: ( ) __ __ __ - __ __ __ __
Products/Services Sold:_____________________________ Email: ________________________________
Type of Business: _________________________________________________________________________
Federal Tax ID or SSN #: __ __-__ __ __ __ __ __ __ No. of Employees_________
******************************************************************************************
OWNER’S INFORMATION
Owner / Partner / Officer Name:_________________________________________DOB:________________
SSN #:__ __ __-__ __-__ __ __ __ Home Phone #: ( ) __ __ __-__ __ __ __Cel: ( ) __ __ __-__ __ __ __
Home Address ________________________________________________________________
Notes: ____________________________________________________________________________________
__________________________________________________________________________________________
Jermaine Brown
Account Executive
First Data Commercial Svcs.
877-457-2615 ext 6247
800-685-3312 fax
jermaine.brown@firstdata.com
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