Contact InformationContact Information

*
*
*
*
*

Owner InformationOwner Information

*
*
*
*
*

Business InformationBusiness Information

*
*
*
*
*
*
*
*
*
*

Business AddressBusiness Address

*
*
*
*

Mailing AddressMailing Address

*
*
*
*

Owner AddressOwner Address

*
*
*
*
*
*
*
*

Transaction InformationTransaction Information

*
*
*

Funding informationFunding information

*
*
*
*

Second Owner informationSecond Owner information

Second Owner AddressSecond Owner Address

Submit Secure ApplicationSubmit Secure Application

Please confirm that your business is not related to the following industries:

My business is not related to the internet casino or gambling industry
By providing your information and registering, you are agreeing to the Terms and Conditions
The Merchant and Owner(s)/Officer(s) identified above (individually, and/or together, the "Applicant”) each represent, acknowledge and agree that (1) all information and documents provided to Representative including credit card processor statements are true, accurate and complete, (2) Applicant will immediately notify Representative of any change in such information or financial condition, (3) Applicant authorizes Representative to disclose all information and documents that Representative 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 Assignees, in connection with potential Transactions, (4) Representative and each Assignee will rely upon the accuracy and completeness of such information and documents, (5) Representative, Assignees, 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 the recipient deems necessary, (6) Applicant waives and releases any claims against Recipients 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. A copy of this authorization may be accepted as an original. The term “Representative” shall mean any funding source looking to offer, make available, or provide to the Merchant access to loans or merchant cash advances based on such Merchant’s future receivables or sales and/or structured with a periodic repayment feature.
Please electronically sign by entering your first and last name starting and ending with a /
Example /john doe/