Credit Application

Position:

Phone:

Fax:

Physical Address:

Mailing Address/Billing Address:

State of Incorporation/Organization:

Specific Type of Business:

E-Mail Address

Web Address

Merchant's Legal Name:

D/B/A:

Federal ID:

Amount Requested:

Use of Proceeds:

Date Business Started: (mm/yy)

Length of Ownership:

Describe Specific Type of Product/Service Sold:

Date of Birth:

Position:

Percentage of Ownership:

Cell Phone:

Residence Address:

Length at Current Residence:

Prior Address, City, State, Zip, if at Current Address less than 2 Years:

Date of Birth:

Position:

Percentage of Ownership:

Cell Phone:

Residence Address:

Length at Current Residence:

Prior Address, City, State, Zip, if at Current Address less than 2 Years:

Total Gross Monthly Volume:

Total Annual Gross Volume:

Annual Visa/MC Sales:

Visa/MC Monthly Volume:

Credit Card Processing Company

# of Terminals:

Terminal Make & Model:

American Express Yes No

American Express Account #:

Software Type/POS System:

Contact Name & Phone:

Bank Name:

Phone Number:

Company:

Contact Name:

Company:

Contact Name:

Company:

Contact Name:

Phone Number:

Fax:

Phone Number:

Fax:

Phone Number:

Fax:

Own/Lease:

Lease Start Date:

Lease Term:

Monthly Rent/Mortgage:

Type of Building:

Square Feet (approximate):

Landlord/Mortgage Company:

Contact Name:

Phone Number:

Fax: