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Business Legal Name

DBA Name (If Any)

Type of Business Entity

Corporation

LLC

Partnership

Ltd Partnership

LLP

Sole Proprietor

Does the Merchant have Federal Tax ID: any open MCA or loan accounts?

Yes

No

Current CreditCard Processor

Use of Proceeds

Merchant Email Address

City & State

Zip Code

Billing Street Address (If differentthan above)

Billing State

Location Phone #

Business Location(s)

Rented

Mortgaged Monthly

Avg. Monthly Credit Card Volume

Business OBA Name

Tax ID Number

Primary Business Structure

Home-Based Business

Franchise

E-Commerce

None of above

Industry Type

State of Incorporation

Business start date under current Ownership

Physical Street Address

State

Physical Location Phone #

Billing City

Billing Zip Code

Preferred Contact Phone #

Payment

Avg. Transaction Amount

Gross Annual Sales (from previous year’s Tax return)

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