Mom & Pop Business Funding Application
“MOM & POP TO THE RESCUE”
A. BUSINESS INFORMATION
Legal/ corporate name:
*
DBA:
Physical Address:
City / State / Zip:
Business Phone:
-
Area Code
Phone Number
Fax:
-
Area Code
Phone Number
Federal Tax ID:
Contact:
E-mail:
*
Website:
Date Business Started:
-
Month
-
Day
Year
Date
Length of ownership:
Years at Location:
# of locations:
B. OWNERSHIP
*(Must Have at Least 67% Ownership, if not, add additional owners on additional applications)
Name:
Contact Phone Number:
-
Area Code
Phone Number
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth:
*
Please select a month
January
February
March
April
May
June
July
August
September
October
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December
Month
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Day
Please select a year
2026
2025
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1920
Year
SSN:
% Ownership of company
*Must have at least 67% ownership
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C. LEASE
*(Landlord Information)
Landlord name:
Contact:
Monthly rent:
Phone:
-
Area Code
Phone Number
BUSINESS PROFILE
Ownership:
*
Sole Proprietor
Partnership
Corporation
LLC
Merchant Type
Retail
Restaurant
Lodging
Service
Internet
Home Based
Automotive
Other
Cards Accepted:
Visa
MasterCard
American Express
Discover
F. CASH ADVANCE
Amount Requested:
(We provide up to 2 times a companies gross monthly bank revenue)
Average Visa / MasterCard monthly sales:
Average gross monthly sales:
Average ticket size:
Have you used a cash advance plan before?
If so, what company did you use?
Original Balance:
Current Balance? (Provide Original Contract)
Current payment or daily holdback %
G. OTHER INFORMATION
Current processing company:
Upload 6 most recent business bank account or credit card processing statements below
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H. SIGNATURE
By signing below, the merchant and its owners / principals: (1) certify that all information on and documents submitted in connection with this Application are true, correct and complete and, (2) authorize M&P, its agents, partners, and lenders to receive credit reports and any other information regarding the Merchant and its owners / principals from third parties, in order to verify any information provided on the Application.
Signature
Date:
-
Month
-
Day
Year
Date
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Should be Empty: