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The Merchant Solutions Group Application Form Download

BUSINESS INFORMATION

Legal / Corporate Name:

DBA:

Physical Address:

City:

State:

Zip:

Business Telephone #:

Business Fax #:

Federal Tax ID:

Date Business Started:

Length of Ownership:

Website:

Type of Entity: Sole Proprietorship Partnership Corporation LLC

Other:

Email:

Product/Service Sold:

Est. Monthly Sales:

MERCHANT / OWNER INFORMATION

Corporate Officer / Owner Name:

Title:

Ownership %:

Home Address:

City:

State:

Zip:

Yrs. at Address:

SSN:

Permanent U.S. resident?:

Date of Birth:

Home #:

Cell #:

PARTNER INFORMATION

Partner Name:

Title:

Ownership %:

Home Address:

City:

State:

Zip:

SSN:

Date of Birth:

Home #:

Cell #:

BUSINESS PROPERTY INFORMATION

Business Landlord or Business Mortgage Bank:

Contact Name and/or Account #:

Phone #:

BUSINESS TRADE REFERENCES (Please list at least 1 trade supplier. NOTE: Application cannot be processed without trade reference.)

Business Name:

Contact Name and/or Account #:

Phone #:

Business Name:

Contact Name and/or Account #:

Phone #:

Business Name:

Contact Name and/or Account #:

Phone #:

Current Processing Company & Account Number:

Type / Number of Terminals:

Monthly Volume:

Requested Advance Amount/Intended Use:

Requested Daily Withholding:

Requested Process:

Prior/Current Cash Advance Company & Length of Time With:

Balance:

The Merchant and Owner(s)/Officer(s) identified above (individually, an Applicant) each represents, acknoledges and agrees that (1)all information and documents provided to MERCHANT SOLUTIONS GROUP including credit card processor statements are true, accurate and complete, (2) Applicant will immediately notify MERCHANT SOLUTIONS GROUP of any change in such information or financial condition,(3) Applicant authorizes MERCHANT SOLUTIONS GROUP to disclose all information and documents that MERCHANT SOLUTIONS GROUP may obtain including credit reports to other persons or entities (collectively,Assignees) that may be involved with or acquire commercial loans having daily repayment features or purchases of future receivables including Merchant Cash Advance transactions, including without limitation the application therefor(collectively,Transactions) and each Assignee is authorized to use such information and documents, and share such information and documents with other Assigness, in connection with potential Transactions,(4) each Assignee with rely upon the accuracy and completeness of such information and documents, (5) MERCHANT SOLUTIONS GROUP, Assigness, and each of their representatives, successors, assigns and designees(collectively,Recipients) are authorized to request and receive any investigative reports, credit reports, statements from creditors or financial institutions, verification of information, or any other information that a Recipient deems necessary, (6) Applicant waives and releases any claims against Recipents and any information-providers arising from any act or omission relating to the requesting, receiving or release of information, and (7) each Owner/Officer represents that he or she is authorized to sign this form on behalf of Merchant.

Applicant's Signature:

Date:

Partner's Signature:

Date: