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Merchant Pre-Qualification Form
Items marked with * are required
1
About The Business
2
Financial Information
Sales Rep
*
Please choose the name of the Sales Rep you are working with
Bryan Duelley
Heath Montag
Other
Kraftsman Trailers
M101
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:
*
Choose State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Business start date under current Ownership:
*
MM slash DD slash YYYY
Merchant Email Address:
*
Physical Street Address:
*
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Physical Location Phone Number:
*
Preferred Contact Phone Number:
Gross Annual Sales
*
(from previous year's Tax return)
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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.
Comments
This field is for validation purposes and should be left unchanged.