ATM Placement Worksheet
Section A
ATM Placement Location
Name of Location (Doing Business As)
*
Address of Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Type of Business
*
Sole Proprietor
LLC
C Corp
S Corp
Other
Business Tax ID
*
Merchandise/Service Sold where ATM is deployed
*
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Section B
(Complete only if applicant is Individual or Sole Proprietor)
Applicant Name
First Name
Last Name
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant Social Security Number
Applicant Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Applicant Phone Number
-
Area Code
Phone Number
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Section C
Complete only if applicant is a company (LLC, Corporation, etc.)
Company Legal Name
Company Legal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Federal Employee Identification Number (FEIN)
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Section D
Bank Account Information
Bank Name
*
Name on Account
*
Bank Phone Number
-
Area Code
Phone Number
Bank Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Account Type
Checking
Savings
Routing Number
*
Account Number
*
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Should be Empty: