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 BUSINESS INFORMATION
RETAIL BUSINESS NAME/DBA (Doing Business As): YEARS IN BUSINESS:
CORPORATE OR LEGAL NAME (If different than above): FEDERAL TAX ID # (EIN #) :  
RETAIL BUSINESS (DBA) ADDRESS: VERIFY FEDERAL TAX ID # (EIN#):
CITY: STATE: ZIP: TOTAL BUSINESS ANNUAL SALES: PROJECTED ANNUAL SALES W/ GE:
$ $
BUSINESS (DBA) PHONE#: BUSINESS (DBA) FAX#: PERCENTAGE OF "FACE TO FACE" TRANSACTIONS
AT BUSINESS LOCATION: %
- - - -
NUMBER, IF ANY, NEEDED TO DIAL OUTSIDE LINE:
(FOR EXAMPLE, MUST DIAL "9" TO DIAL OUT)

 PRINCIPAL INFORMATION (Must be President, Owner, or Partner ONLY)
FIRST NAME: LAST NAME: PRINCIPAL TITLE:   SOCIAL SECURITY NUMBER:
 
PRINCIPAL HOME ADDRESS: RESIDENCE HOME TELEPHONE NUMBER: VERIFY SOCIAL SECURITY NUMBER:
CITY: STATE: ZIP:
     

 BILLING INFORMATION (Complete if different than Retail Business Address above)
BILLING ADDRESS:

CITY: STATE: ZIP:
BANK TRANSIT NUMBER (See image right):
   Please verify:   
BANK ACCOUNT NUMBER (See image right):
   Please verify:   

 TERMS & CONDITIONS
This Business Application ("Application") is submitted to obtain merchant processing privileges on behalf of the person or entity listed in the Principal and Business Sections listed above (“Applicant”) and I/we (hereinafter the individuals submitting this Application are referred as “I” or “my” or “me”) certify that I have read the above provisions and all information provided herein is true and correct. I have the power and authority to execute and deliver this Application and to enter into and consummate the Business Agreement (“Business Agreement”) on behalf of the Applicant, and I have been duly authorized to bind the Applicant, by my submitting this Application for processing, to all terms and conditions of the Business Agreement. The number shown on this form is the correct taxpayer identification number for the entity. I acknowledge that this Application is subject to approval by GE Money Bank ("GEMB").

By submitting this Application, I authorize and/or confirm as follows:

(I) 
 I authorize GEMB or its agents to retain possession of this Application, to rely on the information and statements herein to check and verify both my credit and employment history and the credit history of the Applicant and any of its other principals, officers, partners, or directors, to secure follow up credit reports, and to exchange information about the entity and this account with creditors, credit bureaus, and other proper persons;
(II) 
 I authorize the Applicant’s bank and any other listed references to release and/or verify information to GEMB at any time;
(III) 
 I authorize and permit GE Retail Sales Finance and/or GEMB or its affiliates to send email and/or fax communications to the Applicant to the email address(es) and fax number(s) listed in Sections A & F (or to any email addresses or fax numbers the Applicant may provide in the future) regarding our consumer credit financing relationship or other matters; and
(IV) 
 I certify, represent, and acknowledge that the Applicant has agreed to abide by all terms and conditions of the Business Agreement and that if and when GEMB approves this Application, upon receipt of notice of such approval, the Applicant will, without further action, be bound to all of the terms and conditions of the Business Agreement and any operating guides which shall be issued by GEMB from time to time.
(V) 
 I certify, represent and warrant that this Application has been duly executed and delivered by me on behalf on behalf of the Applicant, and that the execution and delivery of this Application and the consummation of the transactions contemplated by the Business Agreement have been authorized by all necessary corporate action and do not and will not conflict with the organizational documents of the Applicant.