BUSINESS INFORMATION

Legal/Corporate Name*

DBA*

Physical Address*

City*

State*

Zip*

Telephone *

Fax *

Federal Tax ID*

Date Business Started*

Length of Ownership*

Website

Type of Entity*

Email Address*

Type of Business*

Product/Service Sold*

MERCHANT/OWNER INFORMATION

Corporate Officer/Owner Name*

Title*

Ownership %*

Home Address*

City*

State*

Zip*

SSN

Date of Birth*

Home *

Cell *

PARTNER INFORMATION

Partner Name*

Title*

Ownership %*

Home Address*

City*

State*

Zip*

SSN*

Date of Birth*

Home *

Cell*

BUSINESS PROPERTY INFORMATION

Business Landlord/Mtg Bank*

Contact Name and/or Acct*

Phone *

Monthly Rent Amount*

BUSINESS TRADE REFERENCES
(Please list at least 3 trade suppliers. Please attach any additional references on a separate page.)

Business Name*

Contact Name and/or Acct *

Phone*

Business Name*

Contact Name and/or Acct *

Phone*

Business Name*

Contact Name and/or Acct *

Phone*


AGENT USE ONLY

Processing Company*

Number of Terminals*

Terminal Type*

Leased/Owned: *

Requested Advance Amount:

Requested Daily Withholding:

Monthly CC Volume:

Monthly Gross Volume:

Prior/Current Cash Advance Company

Balance*

Current Advance Holdback: *

Please complete and sign Application.

Submit:

6 months Merchant Statements.           (all the pages)

4 months Business Bank Statements.   (all the pages)

Be sure to have all Partners sign.  (If applicable)

 

 

Be prepared to include the following:

  • Business License
  • Drivers License
  • Voided Check (for deposit)
  • Utility Bill
  • Lease Agreement  (1st and last page/legal terms and signature page)
  • Landlord/Banks  direct contact #

 

IF property is owned:  Mortgage Statement