Pirate's Gold - Merchant Application

Name of Business / DBA:

 

Business Address (Include City and Zip Code):

Name of Store Manager: 

Store/Corporate Web Site URL:

Business E-Mail:

Corporate Owner Name (The entity which owns the above business):

Corporate Owner Address (Include City and Zip Code):

Corporate Phone Number:

State where business was incorporated / Type of Corporate Entity:

Name and CORPORATE TITLE of person signing legal agreement:

Number of years in business:

Years business has been in this location:

Type or Description of Business:

Alcohol to be sold on premises?: -- Yes No

Reimbursement Address (Where you want checks mailed):

 

Your Federal Tax ID #:

Upon completion, please fax or mail this application to:
Mary Goff, Director of Campus ID
Seton Hall University
400 South Orange Avenue
Duffy Hall, Room 63
South Orange, NJ 07079
Phone: (973) 761-9771
FAX: (973) 275-2084