Name of Business
Nombre de el Negocio
|
Federal Tax ID #
Numero de Identificacion Federal (IRS)
|
DBA
Nombre Ficticio del Negocio
|
Telephone
Telefono
|
Business Address
Direccion del negocio
|
City, State, Zip
Ciudad, Estado, Codigo Postal
|
E-mail Address
Email
|
Date Business Started
Fecha de apertura del negocio
|
Type of Business
Tipo de Negocio
|
Celular Phone
Celular
|
Business Organization
Corporation
Partnership
Sole Proprietorship.
|
Officer/Title
|
Ownership %
Co-Signer |
List below any Current or Previous Activity as an Agent of a Money Order and/or Money Transmitter Company
Company
Compaņia
Starting Date
Fecha de Apertura
Ending Date
Fecha de Clausura
State
Estado
Reason of Change
Razon del cambio
|
Are you a US Citizen?
Es usted Ciudadano de Los Estados Unidos?
|
Drivers License
No. De Liciencia de manejar
|
Full Name
Nombre Completo
|
Social Security #
Numero de Seguro social
|
Date of Birth
Fecha de Nacimiento
|
Place of Birth
Lugar de Nacimiento
|
Home Address
Direccion Completa
Rent
Own |
City, State, Zip
Ciudad, Estado, Codigo Postal
|
Home Phone
Telefonoo de la Casa
|
Have you ever been convicted of a felony?
Yes
No
If yes, please Explain:
|
Have you ever been involved in a civil or criminal proceeding in violation of the bank secrecy act, or money laundering?
Yes
No |
| |
|
| |
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