Secured Online Mom & Pop Business Funding Application

A. Business Information

Legal/corporate name: *

DBA

Address *

City *

State *

Postal code *

Business Phone *

Fax

Federal Tax Id:

Contact First Name *

Conatact Last Name *

Contact Email *

Website

Date business started: *

Length of ownership: *

Years at location: *

# of locations: *

B. Ownership (Must have at lest 67% ownership. If NOT, add additional owners on additional applications.

Owner's Full Name *

Owner Phone Number *

Owner Home Address *

Owner Date of Birth: *

Owner SSN: *

Company Ownership Percentage: *

Title: *

C. Lease (Landlord Information)

Landlord name: *

Landlord Contact: *

Landlord Phone: *

Monthly rent: *

D. Business Profile

Ownership Structure: *

Merchant type: *

Cards accepted: *

E. Cash Advance

Amount requested: (Up to 2x gross monthly bank revenue) *

Average Visa/MasterCard monthly sales: *

Average gross monthly sales: *

Average ticket size: *

Have you used a cash advance plan before? *

If so, what company did you use?

Original Balance:

Current Balance? (Provide Original Contract)

Current payment or daily holdback%

F. Other Information

Current processing company:

Referred By

Bank Documents (Last 6 month statements)

IMPORTANT: Once you submit your information, check your email (spam/promotions folder as well) for an electronic application for you to review and sign. It will come from brian@bchbizdevelopment.com. Thank you!