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A. business information
Legal / Corporate Name *
DBA
Business Phone *
Physical address:
City
State
Zip Code
Fax
Federal Tax ID
Contact *
Email *
Website
Date Business Started
Length of Ownership
Years at Location
B. OWNERSHIP
Name:
Home phone:
Cell phone:
Home address:
City:
State:
Zip:
Date of Birth *
SSN *
Driver's License # *
State Issued
% Ownership *
Title
C. leasing information
Landlord name
Contact:
Work phone:
Work phone:
Fax
Monthly Rent
Square Feet
Lease Start / End Dates
E. business profile
Ownership:
Sole proprietorship
Corporation
Partnership
LLC
CARDS ACCEPTED
Visa
MasterCard
American Express
Discover
Merchant type:
Retail
Internet
Home-based
F. CASH ADVANCE / G. OTHER INFORMATION
Avg. Visa/MasterCard Monthly Sales
Used Cash Advance Before?
Average Gross Monthly Sales
Company
Original Balance
Current Balance
Current Processing Company
H. SIGNATURE
Signature:
Date
Submit Your Loan Details
