BUSINESS FUNDING APPLICATION

BUSINESS FUNDING

One Page Application
SHOP LOCAL

We Support Our Small Businesses
MOM & POP BUSINESS FUNDING APPLICATION
"MOM & POP TO THE RESCUE”
A. Business Information
Legal/corporate name
DBA
Address

Physical address

Street Address Line 2

CityState

Zip
Business phone
Fax
Federal tax ID
Contact
E mail
example@example.com
Website
Date business started

MonthDayYear
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:
Address

Home address

Street Address Line 2

CityState

Postal / Zip Code
Zip:
Date of birth

MonthDayYear
Date
SSN
% Ownership of company
Must have at least 67% ownership*
Yes or No response required
Title
C. LEASE *(Landlord Information)
Landlord name
Contact
Monthly rent
Phone
E. BUSINESS PROFILE
Ownership

Sole proprietorshipCorporationPartnershipLLC
Merchant Type

RetailInternetRestaurantHome-basedLodgingAutomotiveServiceOther
Cards Accepted

VisaMastercardAmerican ExpressDiscover
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
K. 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

Clear
Date

MonthDayYear
Date
File Upload*

6 Months Bank Statements
Cancelof
Should be Empty:

BUSINESS FUNDING

SHOP LOCAL

MOM & POP BUSINESS FUNDING APPLICATION

"MOM & POP TO THE RESCUE”