Merchant Cash Advance Application Form

Merchant Cash Advance Application

Business Information
LEGAL CORPORATE NAME*
DBA*
PHYSICAL ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
TELEPHONE *

Area CodePhone Number
FAX

Area CodePhone Number
STATE OF INCORPORATION*
FEDERAL TAX ID *
DATE BUSINESS STARTED*

MonthDayYear
LENGTH OF OWNERSHIP*
EMAIL ADDRESS *
WEBSITE
Sole ProprietorPartnershipCorporationLLCOther
RetailMo/ToWholesaleRestaurantSupermarketOther
PRODUCT/SERVICE SOLD*
MERCHANT/OWNER INFORMATION
OWNER NAME*

PrefixFirst NameMiddle NameLast Name
CORPORATE OFFICE NAME
TITLE*
OWNERSHIP%
HOME ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
SSN*
DATE OF BIRTH*

MonthDayYear
HOME#*

Area CodePhone Number
CELL#*

Area CodePhone Number
PARTNER INFORMATION
OWNER NAME

PrefixFirst NameMiddle NameLast Name
CORPORATE OFFICE NAME
TITLE
OWNERSHIP%
HOME ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
SSN
DATE OF BIRTH

MonthDayYear
HOME#

Area CodePhone Number
CELL#

Area CodePhone Number
BUSINESS PROPERTY INFORMATION
BUSINESS LANDLORD OR BUSINESS MORTGAGE BANK*
CONTACT NAME AND/OR ACCOUNT#*
PHONE#*

Area CodePhone Number
BUSINESS TRADE REFERENCES

(Please list at least 3 trade suppliers)
BUSINESS NAME*
CONTACT NAME AND/OR ACCOUNT# *
PHONE#*

Area CodePhone Number
BUSINESS NAME*
CONTACT NAME AND/OR ACCOUNT# *
PHONE#*

Area CodePhone Number
BUSINESS NAME*
CONTACT NAME AND/OR ACCOUNT# *
PHONE#*

Area CodePhone Number
BUSINESS NAME
CONTACT NAME AND/OR ACCOUNT#
PHONE#

Area CodePhone Number
PROCESSING
PROCESSING COMPANY
TERMINAL TYPE
NUMBER OF TERMINALS
MONTHLY VOLUME
REQUESTED ADVANCE AMOUNT
REQUESTED DAILY WITHHOLDING
REQUESTED PROCESS
ACH / SPLIT
PRIOR/CURRENT CASH ADVANCE COMPANY (IF APPLICABLE)
BALANCE
CURRENT BANK STATEMENTS

Last 3 months only
FIRST MONTH *

Upload a File

Cancelof
SECOND MONTH*

Upload a File

Cancelof
THIRD MONTH *

Upload a File

Cancelof
CREDIT CARD PROCESSING STATEMENTS

Last 3 months only
FIRST MONTH

Upload a File

Cancelof
SECOND MONTH

Upload a File

Cancelof
THIRD MONTH

Upload a File

Cancelof
Loan Amount
ConstructionAsset PurchaseRefinancingOther
YesNo
SPONSOR NAME (i.e Who told you about us)
By signing below, the merchant and its owners / principals: (1) certify that all information and documents submitted in connection with this application is true, correct and complete; and (2) authorize Credit Line Capital, its agents, partners, and lenders to receive credit reports and any other information regarding the merchant and its owners and principals from third parties, to verify any information provided on the application. By signing this agreement, the merchant hereby authorizes Credit Line Capital and its affiliates to obtain the 12 most recent monthly reports detailing merchant’s credit card processing activity from its card processor or any agent or other third party utilized by that processor to authorize, clear and/or settle credit card payments. Please fill in the spaces above and mail or fax us the application. By doing o, you are giving Credit Line Capital, as well as its agents and affiliates, permission to review your business and personal credit history in order to provide you with formal funding approval. SIGNATURE:
Date of Signature Upload

MonthDayYear
The information provided in this application shall not be shared to anyone else and is kept confidential
Yes
Full Name

First NameLast Name
Should be Empty:

Merchant Cash Advance Application

MERCHANT/OWNER INFORMATION

PARTNER INFORMATION

BUSINESS PROPERTY INFORMATION

BUSINESS TRADE REFERENCES

PROCESSING

CURRENT BANK STATEMENTS

CREDIT CARD PROCESSING STATEMENTS