Information Form
Thank you for placing your trust in us. Please take a few minutes to complete the form below. We will process your request right away.
Contact Information
First name
*
Last name
*
Date of Birth
*
Financing Amount
SSN/NIN
*
Email
*
Mobile Phone
*
Legal Company Name
*
Doing Business As
Home City
*
Home Address Line 1
*
Home Address Line 2
Home State
*
Home Zip
*
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Business Details
Business address is the same as personal
Business Start Date
*
Industry
State of Incorporation
*
Tax ID / Company Number
*
Company Website
Business Phone
*
Business Address Line 1
*
Business Address Line 2
Business City
*
Business State
*
Business Zip
*
FICO Score
*
Ownership %
*
Number of Employees
Current Business Debt
Bank Name
Entity Type
Do you process credit cards?
Basic Documents
Bank Statement (s)
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Additional Document (s)
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Supported formats are PDF, JPG, JPEG, PNG, TIFF, XLS, XLSX less than 10Mb
Please include last 4 month of business bank statements
Signature
By signing below, each of the above listed business and business owner/officer (individually and collectively, “you”) authorize Premium Merchant Funding, 18 LLC (“PMF”) and each of its representatives, successors, assigns and designees that may be involved with or acquire commercial loans or purchases of future receivables including, without limitation, the application therefor (collectively, “Transactions”) 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, Identity IQ and from other credit bureaus, banks, creditors, government agencies and other third parties (the “Recipients”). You also authorize PMF 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 PMF and to each of the Recipients, on its own behalf and authorize PMF to communicate with the Recipients on your behalf and represent you with the Recipients. You also authorize PMF and each of its Recipients to contact you via text message, automated call or email message at the contact information listed above.
Owner's Signature
*
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