9 4R1

250 Corporate Blvd. Suite L

Newark, DE 19702

EXPRESS APPLICATION
Legal Business Name: FULKSHAULING WEARS
Legal Address: 847 W MAPLE ST FLORA IL 62839
Doing-Business-As Name: FULKSHAULING WEARS
DBA Address: 847 W MAPLE ST FLORA IL 62839
LLC, CORP, etc.: CORP Age of Business: 5

Federal Tax ID: 351460760 Business Phone: 6186990909

Legal Name of Owner: TONY FULK Ownership%: 100

Job Title: CEO 02/14/1952
Home Address: 841 W MAPLE ST FLORA IL 62839
Email: TONYF6125@GMAIL.COM

Website Address: FULKSHAULIING.ICU

Home / Cell Phone: 6186990909 Social Security #: 351460760

Legal Name of Owner: TONY FULK Ownership%: 100

Job Title: CEO 02/14/1952
Home Address: 841 W MAPLE ST FLORA IL 62839
Email: TONYF6125@GMAIL.COM

Website Address: FULKSHAULING.ICU

Home / Cell Phone: 6186990909 Social Security #: 351460760

877.517.4678 phone
PG #1
888.535.7463 fax
 9-4R1
250 Corporate Blvd. Suite L
Newark, DE 19702

EXPRESS APPLICATION
Legal Name of Owner: TONY FULK Ownership%: 100
Job Title: CEO 02/14/1952
Home Address: 841 W MAPLE ST FLORA IL 62839
Email: TONYF6125@GMAIL.COM

Website Address: FULKSHAULING.ICU

Home / Cell Phone: 6186990909 Social Security #: 351460760

Legal Name of Owner: TONY FULK Ownership%: 100

Job Title: CEO
Home Address: 841 W MAPLE ST FLORA IL 62839
Email: TONYF6125@GMAIL.COM

Website Address: FULKSHAULING.ICU

Home / Cell Phone: 6186990909 Social Security #: 351460760

Desired Method(s) of Accepting Payments:

Phone Line Wireless Internet Connected
Mobile Phone Virtual Terminal Shopping Cart
POS Name: Version:
Previous Processing? Yes / No NO AMEX
aily Settlement Time: 8PM
If Yes, How Long?
Average Ticket Amount: 1000
Prev. Processor Name:
Average Monthly Volume: 50000

Please include:
- A copy of a voided check
- A picture of your license
- Last 3 months of processing history (if applicable)

877.517.4678 phone
PG #2
888.535.7463 fax