Merchant Form

Business Legal Name: Legal Entity: CorporationLLCSole Proprietorship Business Phone: Mobile: Email Address: Physical Address:

City State Zip

Doing Business As: Federal Tax ID: Business Start Date: Mailing Address:

City State Zip

Name: Home Address:

City State Zip

% of Ownership: Mobile: Email: Date Of Birth: Social Security Number:

Name: Home Address:

City State Zip

% of Ownership: Mobile: Email: Date Of Birth: Social Security Number:

Business Description: Rented or Owned: Rent/Mortgage Amount:

Open Bankruptcy? Landlord/Mortgage Company Contact:

How Much Capital is being requested? Purpose of the funds? Visa Master Card Monthly Volume?

Total Monthly Sales(All Forms of Revenue):

Do you currently have a Cash Advance?

If Yes, What is the current outstanding balance?

Authorization

By submitting this application, you (the Merchant and Owners/Officers) agree to the following:

* The information provided is true and complete.
* Any changes will be promptly reported.
* You authorize us to share your information with relevant parties for funding purposes.
* You waive any claims against us or information providers.
* The signers are authorized to act on behalf of the Merchant.

I agree to the above terms and authorize The Phoenix Finance to process my application.