Retail Application
How did you hear about us?
*
If a referral, please provide name
Business Legal Name
*
Entity Type
*
Please Select
Sole Prop
LLC
Corporation
Partnership
DBA
*
EIN letter from IRS
*
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Legal Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Phone Number
*
Please enter a valid phone number.
Type of Business
*
Please Select
Brick & Mortar
E-Commerce
Both
If E-Commerce-Web Address and Website Host/Provider Name
*
Mark NA if not e-commerce
If E-Commerce-What is your refund policy?
*
Mark NA if not e-commerce
If E-Commerce-What platform is your website built on? **CANNOT USE WIX**
*
Mark NA if not e-commerce
If E-Commerce, must provide proof of domain ownership
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Business Start Date
*
-
Month
-
Day
Year
Date
Business License
*
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Voided Check
*
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3 months most recent Processing Statements -OR- if a start-up, 3 most recent business or personal bank statements (Full bank statements required)
*
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Products and/or Services sold
*
Owner Information
Owner Name
*
First Name
Last Name
Owner Title
*
% Ownership
*
Owner DOB
*
-
Month
-
Day
Year
Date
Owner Social Security Number
*
Owner Phone Number
*
Please enter a valid phone number.
Owner Email
*
example@example.com
Owner Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Driver's License Number
*
Driver's License Issuing State
*
Owner Driver's License-Front
*
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Owner Driver's License-Back
*
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2nd Owner Information
2nd Owner Name
First Name
Last Name
2nd Owner Title
% Ownership
2nd Owner DOB
-
Month
-
Day
Year
Date
2nd Owner Social Security Number
2nd Owner Phone Number
Please enter a valid phone number.
2nd Owner Email
example@example.com
2nd Owner Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2nd Owner Driver's License Number
2nd Owner Driver's License Issuing State
2nd Owner Driver's License-Front
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2nd Owner Driver's License-Back
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Are there additional owners?
*
Please Select
Yes
No
Financial Information
If a start up, projected volume
Credit & Debit Card Annual Volume
*
Average Monthly Volume
*
Max Monthly Volume
*
Average Ticket Amount
*
High Ticket Amount
*
Submit
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