Prefilled Application Form - Locked - For Merchant Review Application Form Please review the application information you have provided below. Upon approval, please click the button Approve Information and E-Sign to complete your Application Form. Then, click the confirmation link that will be sent to your email address. Business Information Legal/Corporate Name Business Name (DBA) Date the Business was Established Physical Business Address City State Zip Code Physical Mailing Address City State Zip Code Business Phone Number Business Fax Number In what state was the business incorporated? Type of Entity Type of Industry Products Sold and/or Services Offered by your Business Website Address Federal Tax ID Number Average Monthly Credit Card Sales $ Average Monthly Total Sales $ Date Started Current Ownership Do you own another business or location? What do you project your gross sales to be for 2016? $ How much did you file in gross sales for 2015? $ As filed on the income tax return for the year 2014. Have you filed your most recent tax return(2014)? Merchant/Owner Information Salutation First Name Last Name Title % Ownership Home Address City State Zip Code Date of Birth Social Security Number Home Phone Number Cell Phone Number Email Address Second Email Address Third email address Preferred Method of Contact (select all that apply)Business PhoneCell PhoneE-mailFaxSMSHome Phone Contact this owner for the following purposes (select all that apply)Point Of ContactAdd'l Paperwork/ ClarificationReview Funding Offers Second Partner Information Second Owner Name Title % Ownership Home Address City State Zip Code Date of Birth Social Security Number Home Phone Number Cell Phone Number Email Address Second Email Address Third Email Address Preferred Method of Contact (select all that apply)Business PhoneCell PhoneE-mailFaxSMSHome Phone Contact this owner for the following purposes (Select all that apply)Point Of ContactAdd'l Paperwork/ ClarificationReview Funding Offers Third Partner Information Third Owner Name Title % Ownership Home Address City State Zip Code Date of Birth Social Security Number Home Phone Number Cell Phone Number Email Address Second Email Address Third Email Address Preferred Method of Contact (Select Al That Apply)Business PhoneCell PhoneE-mailFaxSMSHome Phone Contact this owner for the following purposes (Select all that apply)Point Of ContactAdd'l Paperwork/ ClarificationReview Funding Offers Fourth Partner Information Full Name (First, Last) Title % Ownership Home Address City State Zip Code Date of Birth Social Security Number Home Phone Number Cell Phone Number Email Address Second Email Address Third Email Address Preferred Method of Contact (Select All That Apply)Business PhoneCell PhoneE-mailFaxSMSHome Phone Contact this owner for the following purposes (Select all that apply)Point Of ContactAdd'l Paperwork/ ClarificationReview Funding Offers Funding Questionnaire Desired Funding Amount Desired Funding Date Desired Repayment Method Does business monthly sales volume fluctuate? Lower Sales Months Higher Sales Months Active Advance Details Funding Company Funded Amount $ Payback Amount $ Repayment Method Retrieval Rate % Fixed Daily Payment $ daily Fixed Weekly Payment $ weekly Balance $ Balance Date Looking to Pay Off Existing Loan? Repayment MethodPlease select... Fixed ACH Daily Payment Fixed ACH Weekly Payment Split-Processor Split-LockBox Split-ACH Percentage of Credit Card Sales Not Paying Current Lender Other Loan StatusPlease select... Active- Making Payments Not Making Payments Paid Off Business Property Information Do you own or lease the business property? Lease Information How much do you pay each month for rent? $ How long have you been operating at this business location? Landlord Name Who can be contacted regarding your tenancy? Office Phone Number Mobile Phone Number Email Address What date did your lease begin? What date does your lease end? Is the business current on rent payments? How many months are you behind on rent payments? Approximately how much is owed on rent? $ Mortgage Information What is the name of the entity / individual that owns the property? How much do you pay each month on your mortgage? $ How long have you been operating at this business location? What is the name of your mortgage company? Who can be contacted regarding your mortgage? Office Phone Number Mobile Phone Number Email Address Is the business current on mortgage payments? How many months are you behind on your mortgage payments? Approximately how much is owed on your mortgage? $ Business Trade References Trade Reference 1: Business Name Contact Name or Account No. Phone Number Email Address Trade Reference 2: Business Name Contact Name or Account No. Phone Number Email Address Trade Reference 3: Business Name Contact Name or Account No. Phone Number Email Address I certify that all of the information above is to the best of my knowledge and belief true, correct and complete.YesNo Please make any necessary corrections in the space provided below: Internal Use Only Offer details Is there loan profile(s)YesNo 3rd owner SalutationPlease select... Mr. Mrs. Ms. Dr. Prof. # of applicants in salesforcePlease select... 0 1 2 3 4 # of emails on file for contact #1Please select... 0 1 2 3 4 5 # of emails on file for contact #2Please select... 0 1 2 3 4 5 # of emails on file for contact #3Please select... 0 1 2 3 4 5 # of emails on file for contact #4Please select... 0 1 2 3 4 5 Does your total sales volume fluctuate?Please select... Yes No Somewhat Is the business current on rent payments?Please select... Yes No Not Provided on App Is the business current on mortgage payments?Please select... Yes No Not Provided on App Do you own or lease the business property?Please select... Lease Owned-Paying Mortgage Owned -Property Fully paid Owner Email Need assistance with this form?
