COMPANY INFORMATION

Loan Amount Requested

Legal Entity Type

Annual Business Revenue

Monthly Credit Card Volume

Current Merchant Processor Name

Terminal Type or Make

Terminal Model Number

Exact Company Legal Name

Company Type/Industry

State of Incorporation

Tax ID Number

Business Address

Business City

Business State

Business Zip

Business Phone#

Business Fax #

Business Landlord Name

Business Landlord Phone

Trade Reference (1)

Trade Reference Phone (1)

Trade Reference (2)

Trade Reference Phone (2)

OWNER INFORMATION (1)

Full Legal Name

Years As Owner 

Home Address

City

State

Zip

Home Phone #

Cell Phone #

% Ownership of Business

Social Security Number#

Date of Birth

E-Mail Address

Drivers License Number

Drivers License State

OWNER INFORMATION (2)

Full Legal Name

Years As Owner 

Home Address

City

State

Zip

Home Phone #

Cell Phone #

% Ownership of Business

Social Security Number#

Date of Birth

E-Mail Address

Drivers License Number

Drivers License State

Additional Message /Comments

Include a copy of your credit card processing monthly statement &

fax all documents and application to (800) 796-7196

How Should We Send Your Application?