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COMPANY INFORMATION
(Check One)
*Address Registered w/ Secretary of State **Location of Business Operations
OWNERSHIP INFORMATION
CREDIT CARD PROCESSING INFORMATION
(Must Equal 100%)
EQUIPMENT / SITE INFORMATION
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FLAT RATE PRICING/FEES (FOR AGENT USE ONLY)
       
AGENT
1 (844)-GROOVE-1
BENEFICIAL OWNER (#2)
BENEFICIAL OWNER (#3)
BENEFICIAL OWNER (#4)
CONTROLLER
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