Email form

- A. Business Information
Legal/Corporate Name: *
DBA: *
Physical Address: *
City: *
State: *
Zip: *
Business Telephone: *
Fax #:
Federal Tax ID: *
Contact Person: *
Email Address: *
Website:
Date Business Started: *
Length of Ownership: *
Years at Location: *
Number of Locations: *
Open Cash Advances *
Company Name:
Amt:
Company Name:
Amt:
Dollar Amount Wanted: *
Use Of Funds: *

+ B. Ownership
Title: *
Name: *
Home Phone: *
Cell Phone: *
Home Address: *
City:*
State:*
Zip:*
Date of Birth:*
SS#:*
Driver's License Number #:*
% Ownership of Company:*

Partner Information:
Title:
Name:
Home Phone:
Cell Phone:
Home Address:
City:
State:
Zip:
Date of Birth:
SS#:
Driver's License Number #:
% Ownership of Company:

+ C. Bank Information
Name of Bank: *
Contact: *
Phone: *

LandLord:
Landlord Name: *
Contact: *
Cell Phone #: *
Work Phone #: *

Trade Suppliers:
Business Name: *
Contact: *
Phone #: *
Business Name: *
Contact: *
Phone #: *
Business Name:
Contact:
Phone #:

+ D. Business Profile
Ownership: *
Merchant Type: *
Visa %
MasterCard %
AMEX %
Discover %
EBT %
Monthly Sales Total of All Cards Together $:

Signature: (This application is legally binding when signed or e-signed )

Applicant authorizes Speed Fund LLC., its assigns, agents, banks or financial institutions to obtain an investigative or consumer report from a credit bureau or a credit agency and to investigate the references given on any other statement or data obtained from applicant. Applicant, by signing below, represents that all the information is complete and accurate. 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. Owner/Officer represents that he or she is authorized to sign this form on behalf of Merchant.

Date:

Applicant’s Signature: (Use Mouse to sign your name)

Partner Signature: (Use Mouse to sign your name)


Fill out application form E-sign,Submit. Please be sure to send in your bank statements and credit card statements if you take credit cards.

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