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1. Business Information (* required field) |
Business Name/DBA *
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Website
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Phone *
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Fax
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Year Business Opened *
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Length of Ownership *
year/s |
Ownership Type *
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Federal Tax ID *
(as it appears on your tax return)
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Tax Filing Name *
(if different, fill in)
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State Business Filed *
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Business Address *
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City *
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State/Zip Code *
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Mailing Address
(if different from Business Address)
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City
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State/Zip Code
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Contact Name *
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Contact Phone (if different from Phone above)
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Contact Email *
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Prior Business Name
(if current company is less than a year old)
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Any prior bankruptcies, business or personal? *
Yes no |
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2. Owner Information |
Owner 1/Partner/Officer Name *
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Title *
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SSN *
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Date of Birth *
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Equity Ownership *
% |
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Home Address *
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City
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State/Zip Code
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Owner 2/Partner/Officer Name
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Title
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SSN
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Date of Birth
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Equity Ownership
% |
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Home Address
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City
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State/Zip Code
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3. Trade References (phone company, internet company, cleaning service etc) |
Trade Reference Name 1
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Contact
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Phone
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Trade Reference Name 2
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Contact
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Phone
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4. Merchant Profile |
Method of Sales
(check all that apply)
Online Shop % of sales
Store Front % of sales |
Do you have seasonal sales? *
Yes no |
Average Transaction Price *
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Maximum Transaction Price *
$ |
Estimated Average Sales (per month) *
$ |
Estimated High Sales (per month) *
$ |
Current Payment Processor (if any)
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Reason for leaving
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