1Business2Ownership3Lease4Official Use5Business Profile6Cash Advance7Other Info8Signature Hiddenhide admin page A. Business InformationLegal/Corporate Name* DBA (optional) Physical Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxFederal Tax ID* Contact* First Last Email* Website Date Business Started* Month Day Year Length of ownership (years)*Years at location*# of locations* B. OwnershipMust have 67% ownership, if not, please add additional owners.Name* First Last Your Email* Phone*Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* MM slash DD slash YYYY SSN* % Ownership of company*Must have at least 67% total ownershipTitle* C. LeaseLandlord InformationNo Lease We do not have a lease/landlord.Landlord* Contact* First Last Monthly Rent*Phone* D. Official Use OnlyOfficial Use E. Business ProfileLegal Ownership* Sole Proprietorship Corporation Partnership Limited Liability Company (LLC) Merchant Type* Retail Restaurant Lodging Service Internet Home-Based Automotive Other Cards Accepted* Visa MasterCard American Express Discover F. Cash AdvanceMaximum amount is 200% of gross monthly bank revenue.Amount Requested*Average Visa/Mastercard monthly sales?Average gross monthly sales?Average ticket size?Have you used a cash advance plan before? Yes No Which company did you use? Original BalanceCurrent Balance?Contract required.Current payment or daily holdback %Please upload your contract*Accepted file types: pdf, jpg, png, Max. file size: 50 MB. G. Other InformationCurrent credit card processing company* H. SignatureTerms & Conditions* By signing below, the Merchant and its owners/principals: (1) certify that all information on and documents submitted in connection with this Application are true, correct, and complete; and (2) authorize Elite Lending Team LLC, M&P, its agents, partners, and lenders to receive credit reports and any other information regarding the Merchant and its owners/principals from third parties, in order to verify any information provided on the Application. Date* MM slash DD slash YYYY Signature* Δ