Merchant Services Across the South and East Coast

Merchant Application

Please complete the application below and a representative will be in touch with you shortly.

Basic Information

Agent Name (required)

Requested Advance Amount (required)

Intended Use of Funds (required)

Business Legal Name (required)

Business DBA Name

Business Physical Address

Address Line 1 (required)

Address Line 2 (Apt/Fl/Ste)

City, State & Zip (required)

Business Mailing Address

Address Line 1 (required)

Address Line 2 (Apt/Fl/Ste)

City, State & Zip (required)

Telephone (required)

Business Email (required)

Business Website

Type of Business Entity (required)
 Corp LLC Partnership Sole Prop Other

Federal Tax ID (required)

Estimated Annual Income (required)

About Your Business

Type of Business (required)
 Retail Restaurant Hotel/Lodging Services Internet/eCommerce Wholesale

Other

Owner #1 Information

Full Name (required)

Official Title (required)

Address Line 1 (required)

Address Line 2 (Apt/Fl/Ste)

City, State & Zip (required)

Phone (required)

Email (required)

Date of Birth (MM/DD/YYYY)

% Ownership

Owner #2 Information

Full Name

Official Title

Address Line 1

Address Line 2 (Apt/Fl/Ste)

City, State & Zip

Phone

Email

Date of Birth

% Ownership

References

Landlord/Mortgage Company (required)

 Own Rent

Lease Expiration

Phone

Fax

Contact Name

Monthly Payment

Additional Information

Average Total Monthly Sales $ (required)

Average Total Monthly Visa/MC/AMEX Sales $ (required)

Ever have a cash advance?
 Yes No
If yes, from who?

Current Balance $

Please describe any Suits, Judgements, or Liens (open or pending)

Can’t submit online? Please click here to download the application, and mail or fax when completed.