Merchant Funding Application
How many signers will there be?
Please Select
1
2
Please Choose
*
Corporation
LLC
Partnership
Limited Partnership
Limited Liability Partnership
Sole Proprietor
Seasonal Sales
*
Yes
No
Please select your high volume months?
January
February
March
April
May
June
July
August
September
October
November
December
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Business Information
Merchants Legal Name
*
D/B/A
Federal ID (or SS# for Sole Proprietorship)
*
Address
*
Physical Address
Street Address Line 2
City, State, Zip
State / Province
Postal / Zip Code
Mailing Address (If different from physical address)
Mailing Address / Billing Address (if different)
Street Address Line 2
City, State, Zip
State / Province
Postal / Zip Code
Business Phone Number
*
Business Fax Number
State of Incorporation
*
Business Industry
*
Date Business Started(mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
Length of Ownership (Time in business)
*
Ex: 6 months, 1 year
Use of Proceeds
*
Web Address
Any other businesses operating out of the same location? If yes, please list
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Company Ownership
Authorized Signers
Ownership 1:
Owner or Authorized Officer Name
*
% of Ownership
*
Ex: 50%
Social Security Number
*
Date of Birth
*
/
Month
/
Day
Year
Date
Position
*
Driver’s License # & State
*
Contact Phone Number
Cell Phone Number
*
Address
*
Residence Address
Street Address Line 2
City, State, Zip
State / Province
Postal / Zip Code
Email Address
*
Ownership 2
Name
% of Ownership
Ex: 50%
Social Security Number
Date of Birth
/
Month
/
Day
Year
Date
Position
Ex: Managing Partner / President
Driver's License # & State
Address
Residence Address
Street Address Line 2
City, State, Zip
State / Province
Postal / Zip Code
Email Address
example@example.com
Home Phone
Cell Phone Number
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Requested Amount / Sales & Credit Card Processing
Requested Amount
*
Ex: 50000.00
Avg. Gross Monthly Income
*
Ex: 50000.00
# of Terminals
Credit Card Processor
Terminal Make & Model
Software Type/POS System
Contact Name & Phone
Do you have an open loan or merchant cash advance balance?
*
Yes
No
If yes, with whom?
Have you used a loan or merchant cash advance program before?
*
Yes
No
If yes, company(s)
Is there a outstanding loan to a previous business owner?
*
Yes
No
If yes, monthly payment & term?
Any state/federal tax liens against owner?
*
Yes
No
If yes, deails:
Have you or your business declared bankruptcy?
*
Yes
No
If yes, details:
Are any suits or judgments pending?
*
Yes
No
If so, details:
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Property Information
Own/Lease
Lease Start Date
/
Month
/
Day
Year
Date
Lease Term
Monthly Rent/Mtg
Ex: 3000.00
Square Footage approx
Landlord/ Mortage Company
Contact Name
Phone Number
Fax Number
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Would You like to upload your documents now?
*
Please Select
Yes
No
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Bank Statements
Please upload the last 3 months bank statements in a PDF format. No picture files.
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