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CITY <br /> NEW COMPANY APPLICATION <br /> COMPANY INFORMATION <br /> •DBA NAME: City of Everett <br /> CORPORATE NAME(IF DIFFERENTTHANABOVE): City of Everett <br /> CONTACT NAME: Susy Hagen/Andy Lee ♦DBA PHONE#:(425) 257-8612 <br /> •DBA ADDRESS 1(NO PO BOX): 333 Smith Island Road DBA FAX#: <br /> DBA ADDRESS 2: YEAR ESTABLISHED: <br /> *CITY:Everett *STATE: WA *ZIP CODE: 98201 *LENGTH OF CURRENT OWNERSHIP: 0.0 YEARS, 0.0 MONTHS <br /> •BUSINESS COUNTRY OF ORIGIN(HEADQUARTERED): <br /> /GEOGRAPHY FOOTPRINT(ALL COUNTRIES UCBVSED TO DO BUSNESS): USA <br /> *BUSINESS SCOPE OF OPERATIONS(TOTAL NUMBER OFLOCATIONS IN ALL COUNTRIES NCLUONG USA): 1 <br /> +EMAIL ADDRESS: shaugen@everettwa.gov/alee@everettwa.gov MOBILE PHONE#: <br /> OTHER ADDRESS(IF DIFFERENT THAN ABOVE) <br /> 0 MAILING 0 SHIPPING 0 SEE ALSO SPECIAL INSTRUCTIONS (MORE THAN ONE OPTION M4YBESELECTED) <br /> L <br /> DBA NAME:City of Everett PHONE#: (425)257-8612 <br /> CONTACT: Susy Haugen/Andy Lee FAX#: <br /> ADDRESS: 333 Smith Island Road CITY: Everett STATE:WA ZIP CODE:98201 <br /> STATEMENTS/ RETRIEVALS /CHARGEBACKS <br /> STATEMENTS: 0 DBA OR 0 MAILING OR 0 W-9 AUTO SEND:CZ YES 0 No(CHAIN COMPANIES ONLY-MUST INCLUDE CHAIN SET UP FORM) <br /> RETRIEVALS: MAIL To:0 DBA 0 MAILING OR FAX To: ❑DBA 0 MAILING OR EMAIL To: ________ OR 0 ONLINE CASE MANAGEMENT(OCM) <br /> CHARGEBACKS: MAIL To: 0 DBA 0 MAILING AND FAX To: 0 DBA 0 MAILING OR EMAIL To: OR 0 ONLINE CASE MANAGEMENT(OCM, <br /> illPRINCIPAL 1 INFORMATION (INCLUDE ALL ADDITIONAL OWNERS WITH 25%OR GREATER OWNERSHIP ON THE ADDITIONAL OWNERSHIP FORM) <br /> •❑ BENEFICIAL OWNER:PERCENTAGE OF OWNERSHIP % 0 AUTHORIZED SIGNER Et RESPONSIBLE PARTY <br /> - <br /> ♦FIRST NAME: ! ►MIDDLE NAME: ♦LAST NAME: •SSN#: <br /> *HOME ADDRESS: 333 Smith Island Road •DOB: <br /> *CITY: Everett •STATE: WA ♦ZIP CODE: 98201 PHONE PHONE#: <br /> PREVIOUS ADDRESS IF CUF ENTADDRESS 1S LESS THAN 2 YEARS <br /> ►HOME ADDRESS: ►CITY: /STATE: ZIP CODE: <br /> *PRIMARY IDENTIFICATION DOCUMENT: 111111111111111111. ♦DOCUMENT ISSUING AGENCY: <br /> ♦DOCUMENT# ►ISSUE DATE: EXPIRY DATE <br /> PRINCIPAL ADDRESS MATCHES THE ADDRESS ON THE PRIMARY IDENTIFICATION DOCUMENT ABOVE UNLESS OTHERWISE NOTED. I LI ALTERNATE DOCUMENT INCLUDED IF NO ADDRESS MATCH <br /> INDIVIDUAL ID EXEMPTION CLASS: <br /> SOLE PROPRIETORS ONLY: <br /> OCCUPATION: ►EMPLOYER(OR DBA): NA <br /> COUNTRY OF PERMANENT RESIDENCE: USA ►COUNTRY(S)OF CITIZENSHIP: USA <br /> OTHER COMPANY INFORMATION <br /> *AVERAGE SALE AMOUNT: $ •CARD PRESENT % <br /> +TOTAL MONTHLY VISA/MC/AMEX/DISC/UNIONPAY SALES:$ •CARD NOT PRESENT* 0.0 % <br /> *DESCRIPTION OF PRODUCT/SERVICES OFFERED: <br /> •INTERNET* <br /> SPECIAL PROGRAM MCC ONLY: (KIST 101AL 100%) <br /> WHEN DOES THE CUSTOMER RECEIVE THE PRODUCT OR SERVICE'/ *CUSTOMER SERVICE PHONE#AND PREVIOUS PROCESSORREQUREDBELOW <br /> IF NOT SANE DAY, #OF DAYS(INCLUDE SHIPPING TIME FRAME) ►CUSTOMER SERVICE PHONE#:(425) 257-8612 <br /> ►INTERNET:PRODUCT WEBSITE: <br /> PREVIOUS PROCESSOR: <br /> ►INTERNET. "CONTACT Us'EMAIL: <br /> IF SEASONAL,PLEASE CHECK MONTHS CLOSED BELOW. (CUSTOMER MUST CONTACT CUSTOMER SERVICE TO DEACTIVATE AND REACTIVATE ACCOUNT) <br /> ❑JANUARY ❑FEBRUARY 0 MARCH 0 APRIL 0 MAY 0 JUNE <br /> 0 JULY 0 AUGUST 0 SEPTEMBER ❑OCTOBER 0 NOVEMBER 0 DECEMBER <br /> BANK ACCOUNT(CHECKING AccouNTS ONLY) <br /> *DEPOSIT BANK NAME:US Bank ♦ABA/ROLITING#: 125000105 •DDA ACCOUNT#: 153595429009 <br /> BILLING/CHARGEBACK BANK NAME(IFDIFFEREN7): ABA/ROUTING#: DDA ACCOUNT#: <br /> TAPE ID(OPT): <br /> Cr,g- <br /> Initials 2 USA-MSP-ELV-0716 <br />