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)

    CorpLLCPartnershipSole PropOther

    Federal Tax ID (required)

    Estimated Annual Income (required)

    About Your Business

    Type of Business (required)

    RetailRestaurantHotel/LodgingServices Internet/eCommerceWholesale

    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)

    OwnRent

    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?

    YesNo

    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.