Card Form

www.gokulsystem.com

Hitesh Patel: (630) 550 7304 , Bob Patel: (630) 205 9452

Important: Please be assured that any information you enter will be securely encrypted. Sensitive data is stored in compliance with privacy and security standards to protect your privacy.

Store Details

SELECT INDUSTRY:

STORE NAME (DBA Name):

STREET ADDRESS:

CITY:

STATE:

ZIP:

STORE PHONE:

APPROXIMATE INSTALLATION DATE:

Business Info

TAX FILLING NAME:

Enter Legal Name of Business OR TAX FILLING NAME

FEDERAL ID#:

FOOD STAMP:

If Foodstamp Required (FNS No)

FIRM TYPE:

ESTABLISHED YEAR:

Owner Details

FIRST NAME:

LAST NAME:

HOME ADDRESS:

CITY:

STATE:

ZIP:

CELL PHONE:

DATE OF BIRTH:

OWNERSHIP (%):

SSN NO:

EMAIL ADDRESS:

Bank Info

BANK NAME:

ROUTING NUMBER:

ACCOUNT NUMBER:

Credit Card Terminals

PROCESSING:

POS INTEGRATED

STANDALONE

NO. OF TERMINALS:

PRICE OF UNITS:

$ 0

Attachment

*Voided Cheque:

*Driver's License:

Business License:

SS4 Form:

OLD Credit-Card Statements:

If you have uploaded, we will attempt to save your money.

Notes:

By checking this box, I [Owner Full Name] authorize Gokul System Solutions to process recurring ACH withdrawals as per the agreed terms.

I acknowledge that I have read, understood, and agreed to the Terms & Conditions governing this authorization.

I understand that this authorization will remain in effect unless formally revoked in writing. I agree that my digital signature carries the same legal weight as a handwritten signature.