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Merchant Pre-Qualification Form

Items marked with * are required

1About The Business

2Financial Information

Sales Rep*
Business Legal Name:*
Business DBA Name:
Federal Tax ID:
Type of Business Entity:*
Check One
- Corporation
- LLC
- Partnership
- Ltd. Partnership
- LLP
- Sole Proprietor
Industry Type:
State of Incorporation:*
Business start date under current Ownership:*
MM slash DD slash YYYY
Merchant Email Address:*
Physical Street Address:*
Street Address Address Line 2 City State ZIP Code
Physical Location Phone Number:*
Preferred Contact Phone Number:
Gross Annual Sales*
(from previous year's Tax return)

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Your Name*
First Last
Social Security Number:*
Date of Birth*
MM slash DD slash YYYY
Home Phone Number*
Address*
Street Address Address Line 2 City State ZIP Code
AUTHORIZATION
By signing below, each of the above listed business and business owner/officer (individually and collectively, "you") authorize MY Company Funding, LLC. ("MCF") and each of its representatives, successors, assigns and designees ("Recipients") that may be involved with or acquire commercial loans having daily repayment features or purchase of future receivables including Merchant Cash Advance transactions, including without limitation the application therefor (collectively, "Transaction") to obtain consumer or personal, business and investigative reports and other information about you, including credit card processor statements and bank statements, from one or more consumer reporting agencies, such as TransUnion, Experian, and Equifax, and from other credit bureaus, banks, creditors and other third parties. You also authorize MCF to transmit this application form, along with any of the foregoing information obtained in connection with this application, to any or all of the Recipients for the foregoing purposes. You also consent to the release, by any creditor or financial institution, of any information relating to any of you, to MCF and to the recipients, on its own behalf."
Owner / Officer's Signature:*
Date*
MM slash DD slash YYYY
Your Email Address*
Email address where you would like your copy of this form to be sent.
Phone
This field is for validation purposes and should be left unchanged.

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Monday	8:00 AM	–	7:00 PM
Tuesday	8:00 AM	–	7:00 PM
Wednesday	8:00 AM	–	7:00 PM
Thursday	8:00 AM	–	7:00 PM
Friday	8:00 AM	–	7:00 PM

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Merchant Pre-Qualification Form

AUTHORIZATION