CC Merchant Information

DBA Name

% Ownership

 Physical Address

City, ST, Zip

Office Tel

Office Fax

Email

Total Mo. Sales (cc & cash)

Type of Business

Years in Business

Business Open Date

Time Remaining
on Lease

Landlord/Agent Name

Landlord/Agent Tel

Number of Locations

 9-Digit FEIN #

Is Business for Sale?

No Yes

Amount Requsted

 Intended Use of Funds

Ever Filed for Bankruptcy?

No Yes

 Federal or State Tax Liens?

No Yes

Previous Cash Advances?

No Yes  If yes, please supply payoff confirmation

Is Your Business Seasonal?

No Yes

CC Processor Information

Current Processor

Merchant Account #

Terminal Type Currently Used

# of Terminas at Location

Length of Time w/ Processor

Owner Information

Principal Owner Name

Date of Birth

Home Address

City, ST, Zip

Home Tel

Mobile Tel

Time at Home Address

# Years at Prev. Home Addr.

Est. Current Annl. Income

2nd Owner Name

Date of Birth

Home Address

City, ST, Zip

Home Tel

Mobile Tel

Time at Home Address

# Years at Prev. Home Addr.

Est. Current Annl. Income

After submitting, please fax the following to
253 719-8132:

1. Social Security #s of owners
2. Picture IDs
3. Voided business check
4. Last 4 months of Visa/MC Statements