NAME OF YOUR RESTAURANT

LEGAL BUSINESS NAME

BUSINESS ADDRESS

Employer Identification Number (EIN)

BUSINESS START DATE

TYPE OF BUSINESS (PLEASE SELECT ONE OF THE FOLLOWING) TYPE OF BUSINESS (PLEASE SELECT ONE OF THE FOLLOWING) Corporation Individual, Sole Proprietor, or single-member LLC Non-Profit Organization Partnership Limited Liability Company (LLC)

YOUR FULL NAME (LEGAL NAME)

EMAIL ADDRESS

DATE OF BIRTH

HOME ADDRESS

PHONE NUMBER

DRIVER LICENSE NUMBER / STATE

SOCIAL SECURITY NUMBER

BANK NAME

BANK ROUTING NUMBER (For receiving payout)

BANK ACCOUNT NUMBER (For receiving payout)