New Merchant Cash Advance FormIf you are human, leave this field blank.Business InformationLegal Name of Business:*DBA:Street Address:*Mailing Address:Business Telephone:Merchant Customer Service Telephone:Age of BusinessYearsMonthsMerchant Contact Email:*Customer Service Email:Website/URL:Authorized Business Rep or ContactTax Filing Name (as it appears on your income tax return):*Federal Tax ID No.:Business Ownership Type: Sole Prop Private Corp LLCPrincipal's Full Name*Ownership %Date Business AcquiredTitle:Home Telephone:Date of Birth:Social Security No.:Driver's License No.:State:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingExpiration DateHome AddressSettlement Account InformationAccount No.:Routing No.:Bank NameList Type of Business/Products/Services Sold:*Current and ProjectionsThe current and projected number of checks, dollar amount per checks, and the total dollar amount of all checks are extremely important! Please provide as accurate of information as possible, as the information is used for underwriting criteria.Number of ChecksDaily Avg:CurrentProjectedDaily Max:CurrentProjectedWeekly Max:CurrentProjectedMonthly Max:CurrentProjectedReturn RateAVG%MAX%Dollar Amount Per Check:Minimum:CurrentProjectedAverageCurrentProjectedMaximum:CurrentProjectedNSF Return RateAVG%MAX%Total Dollar Amount of ChecksDaily Avg:CurrentProjectedDaily Max:CurrentProjectedWeekly Max:CurrentProjectedMonthly Max:CurrentProjectedRecurring RateAVG%MAX%Estimated Monthly Volume (CC):*Average Ticket:Highest Ticket:*Transaction Method% Face to Face% Mail Order% Telephone Order% Internet% Swiped% Keyed With Imprint% Keyed Without ImprintNo. of Employees:Location: Home/Residential Office/Business DistrictReturn Policy: Full Refund Exchange Only No RefundDo you have a refund policy for Visa/MC/Discover/AMEX sales: Yes NoIf Yes, check one Exchange Store Credit Visa/MC/Discover/AMEX CreditAre You Currently Processing?:* Yes NoName of Current ProcessorHave You Ever Had a Payment Card Processing Relationship Terminated?:* Yes NoType of Terminal:Sales Person:Thank you for taking your time in filling out the quick application form. Should you have any questions or clarifications, please feel free to contact us.BalancedProcessing.com1-800-354-6256[email protected]Guaynabo, Puerto RicoSubmit
