Merchant Enrollment Application

Corporate/Business Name: *

DBA: *

Company Website: *

Date Company Established: *

Address *

City *

State *

Postal code *

Country *

PRINCIPAL/OWNERS/OFFICERS :

Name

Email *

Driver Lic. #

% Business Ownership

Homeowner

Job Title

Cell Phone

Phone *

Date of birth

Social Security Number *

Bank Name

Account #

Bank Routing #

Average Requested Amount : $

How many clients request financing per week?

Brief description of the services/products you provide :

Please include the following information when you submit this form:

Articles of Incorporation :

Most recent Financial Statements (business)

Last three months bank statements

Bank Statement 2

Bank Statement 3

Copy of Business License

Copy of Service Agreement

By uploading our Service agreement we agree that: Pay for the service by: Cash or Finance the purchase price through a Retail Installment Contract executed concurrently with this agreement.

YTD - P&L

YTD - Balance Sheet.