Retriever
The 3 Minute Merchant Application
Fax To:_______________
RAPID
ADVANCE
MERCHANT INFOMATION:
Legal Business Name:
DBA Name:
Physical Adress:
City:
State:
Zip:
Business Phone:
Business Fax:
E-Mail
Ttl Monthly Sales (cc& cash):
Type of Business:
Years in Business:
Business Open Date:
Time Remaining on Site Lease/ Mort:
LandLord? Agent Name:
Landlord? Agent Phone#:
Number of Locations:
9-Digit Federal Tax ID number:
Is your Business for Sale?
Amount Requested:
Have you ever filed for bankruptcy?
yes
no
Intended Use of Cash Advance:
Do you have any federal or State tax liens?
Yes
No
Have you previously had cash advance?
Yes
No
If yes please supply payoff confirmation.
Is your business seasonal?
Yes
No
Credit Card Processor Information:
Current Processor:
Merchant Account Number:
Terminal Type currently used:
Number of terminals at Location:
Length of Time with Current Processor:
Years:
Months:
Principal Owner Information:
Principal owner Name:
Social Security Number:
D.O.B:
Home Address:
City:
State:
Zip:
Home Phone:
Mobile:
% Ownership
How Long at Home Address?
Number of Years at Previous Address?
Estimated Current Annual Income$
2nd Owner Name:
Social Security Number:
D.O.B:
Home Address:
City:
State:
Zip:
Home Phone:
Mobile:
% Ownership
How Long at Home Address?
Number of Years at Previous Address?
Estimated Current Annual Income $
Please Submit the Following with Your Application
completed Three Minute Application
Your Last Four (4) Months of Visa/MasterCard Statements
npc Sales PartnerID:
NPC Sales Partner Name:
Sales Rep ID:
Sale Rep Name:
Last up Dated: 8/2/07