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Event Date (If Applicable)
Event Date (If Applicable)
Quantity
Custom Branding
Yes
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Business Information
Lead Source
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Device Rental
Company Name
Doing Business As (IF NOT SAME AS ABOVE)
TIN
Date of Incorporation
Business Type
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Corporation
Individual Sole Proprietorship
Limited Liability Company
Partnership
Tax Exempt Organization
Ownership Type
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Public
Private
Industry Type
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0742 Veterinary Services
0780 Landscaping Services
1520 General Contractors-Residential and Commercial
1711 Air Conditioning Contractors Sales and Installation
1731 Electrical Contractors
1740 Masonry, Stonework Contractors
1750 Carpentry Contractors
1761 Roofing - Contractors
1771 Contractors Concrete Work
1799 Contractors Special Trade, Not Elsewhere Classified
2741 Miscellaneous Publishing and Printing
2791 Typesetting, Plate Making, Related Services
2842 Specialty Cleaning, Polishing, and Sanitation Preparations
4119 Ambulance Services
4121 Taxicabs and Limousines
4131 Bus Lines, Including Charters, Tour Buses
4214 Delivery Services Local, Freight Carriers
4215 Courier Services Air or Ground
4225 Storage
4722 Travel Agencies and Tour Operations
4789 Transportation Services, Not elsewhere classified)
4814 Telecommunication Service
4900 Electric, Gas, Sanitary and Water Utilities
5013 Motor vehicle supplies and new parts
5021 Office and Commercial Furniture
5039 Construction Materials, Not Elsewhere Classified
5044 Office, Photographic, Photocopy, and Microfilm Equipment
5045 Computers, Computer Peripheral Equipment, Software
5046 Commercial Equipment, Not Elsewhere Classified
5047 Medical, Dental Ophthalmic, Hospital Equipment and Supplies
5072 Hardware Equipment and Supplies
5074 Plumbing and Heating Equipment and Supplies
5085 Industrial Supplies, Not Elsewhere Classified
5094 Precious Stones and Metals
5099 Durable Goods, Not Elsewhere Classified
5111 Stationery, Office Supplies, Printing, and Writing Paper
5137 Uniforms and Commercial Clothing
5192 Books, Periodicals, and Newspapers
5193 Florists' Supplies, Bursery Stock and Flowers
5198 Paints, Varnishes, and Supplies
5199 Non-durable Goods, Not Elsewhere Classified
5200 Home Supply Warehouse Stores
5211 Lumber and Building Materials Stores
5251 Hardware Stores
5300 Wholesale Clubs
5310 Discount Stores
5399 Misc. General Merchandise
5411 Grocery Stores
5462 Bakeries
5499 Misc. Food Stores Convenience Stores and Specialty Markets
5511 "Car and Truck Dealers (New and Used) Sales, Service, Repairs, Parts, and Leasing"
5532 Automotive Tire Stores
5611 Men's and Boy's Clothing and Accessories Stores
5631 Women’s Accessory and Specialty Shops
5641 Children's and Infant's Wear Stores
5651 Family Clothing Stores
5655 Sports Apparel, Riding Apparel Stores
5691 Men's and Women's Clothing Stores
5697 Tailors, Seamstress, Mending, and Alterations
5699 Miscellaneous Apparel and Accessory Shops
5712 "Furniture, Home Furnishings, and Equipment Stores, Except Appliances"
5713 Floor Covering Stores
5719 Miscellaneous Home Furnishing Specialty Stores
5722 Household Appliance Stores
5732 Electronic Sales
5733 Music Stores, Musical Instruments, Piano Sheet Music
5734 Computer Software Stores
5811 Caterers
5812 Eating places and Restaurants
5814 Fast Food Restaurants
5832 Antique Shops Sales, Repairs, and Restoration Services
5932 Antiques
5933 Pawn Shops and Salvage Yards
5940 Bicycle Shops Sales and Service
5941 Sporting Goods Stores
5942 Book Stores
5943 Stationery Stores, Office and School Supply Stores
5944 Watch, Clock, Jewelry, and Silverware Stores
5945 Hobby, Toy, and Game Shops
5946 Art/Photo/Film
5947 Card Shops, Gift, Novelty, and Souvenir Shops
5962 Direct Marketing Travel Related Arrangements Services
5963 Direct Selling Establishments/Door-To-Door Sales
5969 Direct Marketing Not Elsewhere Classified
5970 Artist’s Supply and Craft Shops
5971 Art Dealers and Galleries
5973 Religious Goods Stores
5975 Hearing Aids Sales, Service, and Supply Stores
5977 Cosmetic Stores
5992 Florists
5994 News Dealers and Newsstands
5995 Pet Shops, Pet Foods, and Supplies Stores
5996 Swimming Pools Sales, Service, and Supplies
5999 Miscellaneous and Specialty Retail Stores
6300 Insurance Sales, Underwriting, and Premiums
6513 Real Estate Agents, Managers - Rentals
7011 Lodging Hotels, Motels, Resorts, Central Reservation Services
7032 Sporting and Recreational Camps
7217 Carpet and Upholstery Cleaning
7221 Photographic Studios
7230 Barber and Beauty Shops
7261 Funeral Service and Crematories
7276 Tax Preparation Service
7296 Clothing Rental Costumes, Formal Wear, Uniforms
7298 Health and Beauty Shops
7299 Miscellaneous Personal Services ( not elsewhere classifies)
7311 Advertising Services
7333 Commercial Photography, Art and Graphics
7342 Exterminating and Disinfecting Services
7349 Cleaning and Maintenance, Janitorial Services
7372 Computer Programming,
7375 Information Retrieval Services
7379 "Computer Maintenance and Repair Services, Not Elsewhere Classified"
7399 Business Services, Not Elsewhere Classified
7523 Automobile Parking Lots and Garages
7542 Car Washes
7623 Air Conditioning and Refrigeration Repair Shops
7699 Repair Shops and Related Services Miscellaneous
7911 Dance Halls, Studios and Schools
7929 "Bands, Orchestras, and Miscellaneous Entertainers (Not Elsewhere Classified)"
7933 Bowling Alleys
7941 "Commercial Sports, Athletic Fields, Professional Sport Clubs, and Sport Promoters"
7991 Tourist Attractions and Exhibits
7992 Golf Courses Public
7994 Video Game Arcades/Establishments
7997 "Membership Clubs (Sports, Recreation, Athletic), Country Clubs, and Private Golf Courses"
7998 Aquariums, Sea-aquariums, Dolphinariums
7999 Recreation Services (Not Elsewhere Classified)
8011 Doctors and Physicians (Not Elsewhere Classified)
8021 Dentists and Orthodontists
8041 Chiropractors
8043 Opticians, Opticians Goods and Eyeglasses
8050 Nursing and Personal Care Facilities
8062 Hospitals
8071 Medical and Dental Laboratories
8099 Medical Services and Health Practitioners (Not Elsewhere
8111 Legal Services and Attorneys
8211 Elementary and Secondary Schools
8220 Colleges, Junior Colleges, Universities, and Professional Schools
8244 Business and Secretarial Schools
8299 Schools and Educational Services ( Not Elsewhere Classified)
8351 Child Care Services
8398 Charitable and Social Service Organizations
8641 Civic, Fraternal, and Social Associations
8651 Political Organizations
8661 Religious Organizations
8699 Membership Organizations ( Not Elsewhere Classified)
8931 Accounting, Auditing, and Bookkeeping Services
8999 Professional Services ( Not Elsewhere Defined)
9211 Court Costs, Including Alimony and Child Support
9222 Fines
9399 Government Services ( Not Elsewhere Classified)
Business Address
City
State
Zip
Country
Phone
Email
Business Website
Bank Name
Routing Number
Routing Number (Repeat)
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None
Card ACH Application
Virtual Check Application
Account Number
Account Number (Repeat)
Annual Revenue
Average Ticket Size
Highest Ticket Size
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No
Personal Information
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First Name
Last Name
Address
City
State
Zip
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Phone
Email
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Queued
Underwriting
Approved
Declined
SSN
SSN (Repeat)
Date of Birth
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