Merchant Pre-Qualification Form

    Business Legal Name:*

    Business DBA Name:

    Legal Entity (Circle):*
    CorpSole PropLLCPartnership

    Federal Tax ID #*

    State of Incorporation:*

    Business Classification:*
    RetailRestaurantServicesInternetManufacturer/WhoesalerMail Order/Telephone OrderOther

    Physical Address:*

    Mailing Address:

    Business Phone:*

    Business Fax:

    Mobile:*

    Website:

    Email:

    Use of Proceeds:

    Business Start Date :*

    Business Location :*
    Store Front OfficeHomeOther

    Products/Services Provided:*

    Monthly Revenue:*

    Annual Cost of Goods:

    Owner / Principal Information

    Name of Owner 1:*

    Title:*

    % of Ownership:*

    Address home:*

    City, State Zip:*

    Home Phone:

    Mobile:

    Email:*

    Date of Birth:*

    SSN#:*

    Name of Owner 2:

    Title:

    % of Ownership:

    Address home:

    City, State Zip:

    Home Phone:

    Mobile:

    Email:

    Date of Birth:

    SSN#: