BUSINESS

INFORMATION
Legal/Corporate Name: DBA:

Physical Address: City: State: Zip:

Telephone #: Fax #: Federal Tax ID:

Date Business Started: Length of Ownership: Website:

Type of Entity (check one): Product/Service Sold:

Sole Proprietotship Partnership Corporation LLC Other

MERCHANT/OWNER INFORMATION
Corporate Officer/Owner Name: Title: Ownership %:

Home Address: City: State: Zip:

SSN: 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 Mortgage Bank: Contact Name and/or Account #: Phone #: Monthly Rent Amount:

BUSINESS TRADE REFERENCES

Business Name: Contact Name and/or Account #: Phone #:

Business Name: Contact Name and/or Account #: Phone #:

Business Name: Contact Name and/or Account #: Phone #:

AGENT USE ONLY

(Please list at least 3 trade suppliers. Please attach any additional references on a separate page.)
Processing Company: Number of Terminals: Terminal Type: Leased/Owned:

Requeseted Advance Amount: Requeseted Daily Withholding: Monthly CC Monthly Gross Volume:
Volume:

Prior/Current Cash Advance Company (if Balance: Current Advance

applicable): Holdback:
By signing below, the Merchant and its owners / principals: (1) certify that all information and documents submitted in
connection with this Application are true, correct and complete; and (2) authorize MA Financial Solutions, its partners,
funders, and lenders to receive credit reports and any other information regarding the Merchant and its owners and
principals from third parties, to verify any information provided on the application.

Applicant’s Signature Date

Applicant’s Signature Date