Date:

EBT Retailer Information Form

Please complete the below required information to the best of your ability. Include as much information as possible to help speed up the application process. Once received, an agent will contact you within 24 to 48 hours to complete the process.

Tele: 1800-558-6037

Fax: 1-800-642-9634

email: retailer@ebtclientservices.com

Business Information

Legal Business Name:Doing Business As (DBA):

FTID:

EBT/FNS:

(Not required if apply for new services)

How many cash registers do you have?:

Do your registers have scanners ?:

Yes

Type of Business:

Franchise Name:

Franchise Number:

Business Address:

City:

State:

ZIP:

Phone Number

Fax:

Email:

Date business was opened or will be opening:

Business Hours

Monday-Friday:

Saturday:

Sunday:

Retailer Personal(s) Information

Name:

Title:

Birthday:

SSN:

Phone:

Home Address:

City:

State:

Zip Code:

Driver License:

State:

Expiration Date:

Personal Information

Owner's Spouse's Name:

Date of Birth:

SSN:

Phone:

Driver License:

State:

Expiration Date:

Partner / Co-Owner’s Name:

Date of Birth:

SSN:

Phone:

Home Address:

City:

State:

Zip Code:

Driver License:

State:

Expiration Date:

Printed Name:

Date:

Note:

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