Francisco J. Acosta Account Executive Ph: 212-330-0311 Fx: 877-283-7431 Merchant Worksheet Doing Business As Name _____________________________________________________________________________ Corp / Legal Name _________________________________________________________________________________ Address __________________________________________________________________________________________ City _____________________________________________ State _________ Zip ______________________________ Phone # ___________________________________ Fax # ________________________________________________ Email Address _____________________________________________________________________________________ Web Site _________________________________________________________________________________________ Product / Service ________________________________________________ # Employees ________ Business Location Own Lease
Landlord Name _________________________________________ Landlord Phone _____________________________ Private Corp. Sole Ownership Partnership Non-Profit Public Corp.
State Of Incorporation _______ State Or Federal Tax ID # ___________________________ Date Business Started: Month/Year _________________ Date Ownership Started: Month/Year ________________ Total Gross Yearly Sales Volume (Cash & Credit Cards) _______________ Yearly Credit Card Volume _______________ Has Business Ever Declared Bankruptcy? Bank Account Name of Your Bank _____________________________________________ Phone # ____________________________ Branch Contact ________________________________________________ Date Opened ________________________ Address __________________________________________________________________________________________ Signer Information Owner’s Or Officer’s Name _________________________________________ Title _____________________________ Home Address ____________________________________________________________________________________ City _____________________________________________ State _________ Zip ________________ Own Rent Yes No If Yes, when: Month/Year _______________
Home Phone #________________________ Social Security # ____________________ Date of Birth ______________ Driver License Number ____________________ State Issued ________
Francisco J. Acosta Account Executive Ph: 212-330-0311 Fx: 877-283-7431 Signer Information Continued Have You Ever Declared Bankruptcy? Yes No If Yes, when: Month/Year _______________
Spouse’s Name _____________________________________________________________________ Suppliers and References Supplier Name _____________________________________________________________________________________ Phone # _________________________ Product / Service Purchased ________________________________________ Address __________________________________________________________________________________________ City/State/Zip _____________________________________________________________________________________ Supplier Name ____________________________________________________________________________________ Phone # _________________________ Product / Service Purchased ________________________________________ Address __________________________________________________________________________________________ City/State/Zip _____________________________________________________________________________________ Supplier Name _____________________________________________________________________________________ Phone # _________________________ Product / Service Purchased ________________________________________ Address __________________________________________________________________________________________ City/State/Zip _____________________________________________________________________________________ Supplier Name ____________________________________________________________________________________ Phone # _________________________ Product / Service Purchased ________________________________________ Address __________________________________________________________________________________________ City/State/Zip _____________________________________________________________________________________
Francisco J. Acosta Account Executive Ph: 212-330-0311 Fx: 877-283-7431 Signer Information Continued Accountant Information Accountant’s Name ____________________________________________ Phone # _____________________________
Cash Needs (Minimum of $5,000.00 up to a maximum of $1,000,000.00 based upon approved credit.) Total Cash Needed _________________________ When Cash Needed _________________________ Weekly Payment You Can Afford _______________ Pre-Existing Cash/Finance Providers Name of Provider ___________________________________________________________________________________ Amount Funded ____________________ Date Funded ____________________ Rate ____________________ Current Balance ____________________ Do You Wish To Pay Them Off? Yes No
Pre-Existing Credit Card Equipment
Terminal _________________________ Printer _________________________ PIN Pad __________________________
Pre-Existing Merchant Accounts American Express Merchant # __________________________________________________________ Discover Merchant # _________________________________________________________________ Diners Merchant # ___________________________________________________________________ JCB Merchant # _____________________________________________________________________