Processing Agreement for Electronic Returned Item Recovery

Legal Business Name *

Doing Business As

Physical Address *

City *

State

Zip Code *

Mailing Address (If different than physical)

City

State

Zip Code

County *

Number of Locations *

Phone *

Fax

Contact & Title *

Email *

Ownership (Sole Proprietorship, Partnership, LLC, etc...

Year Established *

Federal Tax ID

Social Security Number (proprietorships)

Type of Business *

Products or Services Provided

Average Number of Monthly Returns