Application

Business Funding Application

Please fill in the spaces below and mail or fax us the application. By doing so, you are giving us as well as its agents and affiliates, permission to review your business and personal credit history in order to provide you with formal approval.

Business Legal Name ("Merchant"):

Legal Entity:

Business DBA Name:

Merchant Type:

Address:

Suite/Floor:

Business Location:

City:

State:

Zip:

Federal Tax #:

Business Phone:

Mobile Phone:

Date Business Started:

How Many Locations:

Fax:

Business Type (Products/Services Sold):

Email:

Average Visa/MasterCard Monthly Sales: $

Website:

Total Monthly Average Gross Sales (Cash, Checks, Credit, etc): $

Credit Card Machine (Model/quantity):

Average Credit Sale Size: $

Highest Credit Sale Size: $

POS System Co. Contact Info:

Percent of Card Sales Keyed/Swiped:

Debit Pin Pad (Model/quantity):

Do you Accept Amex : YES NO

Amex #:

OWNER/PRINCIPAL INFORMATION 2ND OWNER/PRINCIPAL INFORMATION

Owner Name:

Owner Home Address:

Owner City:

Owner state:

Owner Zip:

Owner Phone:

Owner Years at Residence:

Owner Email:

Owner % of Ownership:

Owner Date of Birth:

Owner SSN#:

Owner Driver's License #:

2nd Owner Name:

2nd Owner Home Address:

2nd Owner City:

2nd Owner state:

2nd Owner Zip:

2nd Owner Phone:

2nd Owner Years at Residence:

2nd Owner Email:

2nd Owner % of Ownership:

2nd Owner Date of Birth:

2nd Owner SSN#:

2nd Owner Driver's License #:

MISCELLANEOUS INFORMATION

Do you accept EBT / Food Stamps?: YES NO

EBT/Food Stamps Account #:

Amount of Funds Requested:

Have you used a cash advance plan before?: YES/NO
If 'Yes' list previous cash advance provider: Current Cash Advance Balances:

By signing below, the Merchant and its owners/principals: (1) certify that all information and documents submitted in connection with this Application is true, correct and complete; and (2) authorize us, partners, and lenders to receive credit reports and any other information regarding the Merchant and its owners and principals from third parties, to verify any information provided on the Application.

CERTIFICATION & ELECTRONIC SIGNATURE

Applicant Full Name

Title/Position

Email Used to Sign

Date Signed

Electronic Signature

Click or tap here to sign

I agree to the terms above and authorize electronic submission of this application.

Signing Information
IP Address: Auto Captured
Timestamp: Auto Captured
Verification Email: applicant@email.com

Thank you! Your submission has been received!

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Complete Your Business Funding Application

Business Funding Application

OWNER/PRINCIPAL INFORMATION 2ND OWNER/PRINCIPAL INFORMATION

MISCELLANEOUS INFORMATION

CERTIFICATION & ELECTRONIC SIGNATURE