Interstate Billing Service

Please complete the fields below. The asterisk(*) indicates a required field.

Legal Name * Trade Name *
Street Address *   P.O. Box
 
City * State * Zip Code * P.O. Box Zip
Phone Number * Fax Number * Federal ID Number *
Company Type * Corporate ID Number * State of Incorporation *
County * Years in Business * Type of Business *
E-Mail Address Website
Type of Franchises

OWNERS, OFFICIALS & OWNERSHIP PERCENTAGES

Beneficial Ownership Information

Please provide a copy of a valid driver license or government ID for any person with over 10% ownership of your company AND for one person who has the authority to exercise control of the business (such as a CFO, CEO, etc.)
Name * % * Address * SSN * DOB *
Form of ID * State of Issuance * ID Number * Expiration Date *
Name % Address SSN DOB
Form of ID State of Issuance ID Number Expiration Date
Name % Address SSN DOB
Form of ID State of Issuance ID Number Expiration Date
Are all owners U.S. Citizens?
If no, Please explain:

BANK REFERENCES

  Name * Officer's Name * Phone Number *
  Address Account # Fax Number
 
  Name Officer's Name Phone Number
  Address Account # Fax Number
 

TRADE REFERENCES

  Name * Address *
  Account # * Phone Number * Fax Number
 
  Name * Address *
  Account # * Phone Number * Fax Number
 
  Name Address
  Account # Phone Number Fax Number
 

FLOOR PLAN INFORMATION

Floor Plan Source Phone Number  
 
Address Fax Number  
 

KEY PERSONNEL

Name Title Email Phone Number
Who should we contact with questions regarding this application?  
Name of the salesperson with whom you spoke:

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