Merchant Information

Type of EntityCorporationPartnershipSole ProprietorshipOther

* Entity Name:

Business DBA Name:

* Address:

Suite/Floor:

* City:

* State:

* Zip:

* Phone:

Mobile:

Fax:

Website :

* Email :

Fed. ID #:

Business start date

* Responsible Party:

Title:

State of Incorporation:

Current Ownership:

* Product Sold:

Use of proceeds:

 

Principal #1

* Full Name:

Title:

% of Ownership:

* SSN#:

* Address :

* City:

* State:

* Zip:

Home Phone:

Fax:

* Email :

* Mobile:

Driver’s License #:

Driver’s License State:

 

Principal #2

Full Name:

Title:

% of Ownership:

SSN#:

Address :

City:

State:

Zip:

Home Phone:

Fax:

Email :

Mobile:

Driver’s License #:

Driver’s License State:

 

Trade References - Name 3 companies that can vouch for a good pay history.

Company:

Contact Name:

Phone #:

Company:

Contact Name:

Phone #:

Company:

Contact Name:

Phone #:

 

Property Information

Building TypeFree StandingMallHome BasedShopping CenterOfficeOther

Own or Lease?OwnLease

Monthly Rent or Mortgage: $

Lease Start Date:

Landlord / Mortgage Holder:

Time Remaining on Lease:

Contact Name:

Fax or Email:

Address:

City:

State:

Zip:

Phone:

 

Banking Information - Additionally please provide a voided business check.

Bank Name:

Bank Account # :

Contact Name:

Routing # (9 digits):

Branch City:

Branch Zip:

Bank Phone # :

 

Additional Information

Hours of Operation:

Monday

T

W

Th

F

S

Sunday

open: close:

open: close:

open: close:

open: close:

open: close:

open: close:

open: close:

Months of Operation, Check all that apply:JanFebMarAprMayJunJulAugSepOctNovDec

* Describe use of funds:

* How much money do you want? $

Have you ever filed for bankruptcy protection? Are you contemplating Filing Bankruptcy, Reorganization, or an assignment for the benefit of creditors? If so please explain:

Are you current with your rent or mortgage? Are you current with all Payroll, State and Federal Sales tax, etc.? If not please explain::

Please provide the name and phone number of your payroll company, accountant, or other party who is responsible for paying your payroll taxes:: Contact Name:Contact Phone # :

Are there any pending, threatened, or recently filed claims, judgments, tax, liens, or UCC filings against the merchant or guarantor? If so please explain:

Please list all credit card terminals or POS systems being used at this time:

American Express Account Number(s):

Insurance broker / agent::

Is there any outstanding balance with any other cash advance or funding company?

 

12 Months of credit card statements

PDF files only:

 

3 Months of bank statements

PDF files only:

 

Copy of your driver's license(s)

PDF or JPG file:

 

Voided Business Check

Please E-mail or fax: Completed application, 6 months of Merchant statements (All Pages), 4 months of bank statements, a copy of driver license, copy of business license, copy of business lease, if incorporated, include copy of articles of corporation, and a copy of a voided check to

Fax# 661-206-9015 or  E-mail lewisfundinggroup@yahoo.com as a attachment

All documents must be submitted within 48 hours of the completed application being sumitted, to be considered for funding.

 

* I __________________________________hereby certify that all of the information set forth is true and accurate. I authorize Lewis Funding Group, its assigns, and its agents to obtain an investigative report from credit bureaus or credit agencies, and also to investigate the vendor references and any other references given on this application or on any other documents submitted by applicant for the purpose of obtaining funding.

Please print and scan and email back to lewisfundinggroup@yahoo.com for funding request.

 

 

 

 

 

 

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