Vidapay Application

Business Information (Required)

Legal Business Name

Doing Business As ("None" if none)

Federal Tax ID Number

Business Address

City

State

Zip

Store Phone Number

Owner's Information (Required)

First/Last Name Printed

Owner's Date of Birth (00/00/0000)

Owner's Cell Number

Owner's Home Address

Owner's City

Owner's State

Owner's Zip

Please attach a photo or scan of your Driver's License

Please attach a photo or scan of a voided Business Check

Please sign after confirming the above information is correct.

All the above information is correct, and I consent to the submission of this application to T-Cetra (Vidapay)