GENERAL INFORMATION:
Your Email Address:
Legal Business Name
State
D.B.A.
Business Address
Suite
City/State/Zip
Describe Business (Name Product/Service)
Business Hours
% Mail Order
% Phone Orders
% Trade Show
# of Locs
Year Started
Fed Tax ID
State Tax ID (If Retail)
Principal Contact
Title
Phone No.
Fax No.
Est. Card $/Mo.
Avg. $/Sale
Type of Business
Sole Prop.
Partnership
Corp.
State of Incorporation
Age of Business
Date Acquired
OWNER/PRINCIPAL INFORMATION:
President/Owner
Title
% Ownership
S.S.# (Req.)
Residence Address
City/State/Zip
I Own
I Rent, Since
Home Phone
Prev. Address (if less than 3 years)
D.O.B
.
Co-Owner (If Applies)
Title
% Owned
S.S.# (Req.)
Residence Address
City/State/Zip
Since
Own
Rent
Business Location...Type of Building
Commercial
Residential
Retail
Please Rank Your Credit
Prior Chapter 7, 11, 13?
Year
Excellent
Fair
Poor
Yes
No
THANK YOU.
A Merchant Account Representatie Will Contact You Within 48 Hours.