Merchant Application Form

Merchant Application Form

Please fill out the form with accurate information to apply for merchant funding.
Business Information
Business Legal Name*
DBA name
Type of business*

LLCSole memberCorporation
Nature of the Business *
EIN Number*
Business Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Time in business*

MonthDayYear
Date
Business Phone Number*
Please enter a valid phone number.
Business Email*
example@example.com
Funding Request
Requested Funding Amount ($)*
Purpose of Funding*
Qualifying Questions
Is your business currently profitable?*

YesNo
Have you ever declared bankruptcy?*

YesNo
Do you have any outstanding loans?*

YesNo
Property/Advance Details
Property Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Advance Amount Requested ($)*
Owner Information
Owner Full Name*

First NameLast Name
Date of birth

MonthDayYear
Date
Social Security Number *
Owner Phone Number*
Please enter a valid phone number.
Owner Email Address*
example@example.com
Digital Signature*

Clear
Upload Bank Statements *

Cancelof
Should be Empty:

Business Information