NEXT STEPS — Polaris Payments

Legal Business Name *

Legal Business Address *

DBA Name *

DBA Address

If different from legal

Mail statements to: *

Type of Ownership *

Federal Tax ID *

Business Website

http://

What is your average monthly credit card volume? *

What is the highest transaction you expect to run? *

Please provide the following information for each individual who owns 25% or more of the equity interest of your business.

Principal 1 *

Please provide the following information for each individual who owns 25% or more of the equity interest of your business.

Principal 1

First Name

Last Name

Home Address *

SSN *

DOB *

DOB

MM

DD

YYYY

Percent of Ownership *

Principal 2

Principal 2

First Name

Last Name

Home Address

SSN

DOB

DOB

MM

DD

YYYY

Percent of Ownership

Principal 3

Principal 3

First Name

Last Name

Home Address

SSN

DOB

DOB

MM

DD

YYYY

Percent of Ownership