MOM POP BUSINESS FUNDING RESCUE HE

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
Email
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
Address

Home address

Street Address Line 2

CityState

Zip
City
Date of birth

MonthDayYear
Date
SSN
% Ownership of company
Must have at least 67 ownership %
Title
C. LEASE

*(Landlord Information)
Landlord name
Contact
Monthly rent
Phone
D.

*(Left Blank)
E. BUSINESS PROFILE
Ownership:
Merchant Type:
*If selected “other” type below.
Other
Use if selected other above
Cards Accepted
F. CASH ADVANCE
Amount Requested
(We provide up to 2 times a companies gross monthly bank revenue)
Average VisaMasterCard 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
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

Clear
Date

MonthDayYear
Date
Should be Empty:

MOM POP BUSINESS FUNDING APPLICATION

A. BUSINESS INFORMATION

B. OWNERSHIP

C. LEASE

D.

E. BUSINESS PROFILE

F. CASH ADVANCE

G. OTHER INFORMATION

H. SIGNATURE