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FAX COMPLETED APPLICATION TO: (866) 899-3401

188 B Park Avenue | Amityville, NY 11701 | (631) 608.2811 www.citiwidemerchantfunding.com

Merchant Application

Sales Representative # Name WP Contact #

BUSINESS INFORMATION
Type of Entity (check one) Merchants Legal Name Corporation S Corporation General Partnership Nonprofit LLC Other D/B/A Business Phone Business Fax LP Sole Proprietorship LLP Federal ID (or SS# for Sole Proprietorship)

Physical Address

City, State, Zip

Mailing Address / Billing Address State of Incorporation/Organization

City, State, Zip

Use of Proceeds Length of Ownership

Business Type; Product/Service Sold

Date business started (mm/yy)

Contact Name

Position

Email Address

Web Address

Requested Advance Amount

MERCHANT/OWNER INFORMATION (1)

Corporate Officer/Owner Name Title Social Security Number Date of Birth Ownership %

Drivers License & State Residence Address

Home Phone Number

Cell Phone Number City, State, Zip

Email Address

OWNER INFORMATION (2) ONLY IF MERCANT/OWNER (1) IS LESS THAN 50%

Corporate Officer/Owner Name Title Social Security Number Date of Birth Ownership %

Drivers License & State Residence Address

Home Phone Number

Cell Phone Number City, State, Zip

Email Address

SALES & CREDIT CARD PROCESSING INFORMATION

Avg. Gross Monthly Sales (Cash, Checks, Credit Cards) Visa/MasterCard: Card Swipe ______% Manually Keyed______% Seasonal Sales: # of Terminals Yes No If yes, high volume months: Jan Phone/Mail Order ______% Feb Mar Apr Internet ______% Total (100%) May Jun Jul Aug Sep Oct Nov Dec

Terminal Make & Model

Software Type / POS System

Software Type / POS System - Contact Name & Phone

BACKGROUND INFORMATION
Do You Have an OPEN Cash Advance or Dining Program? Used a Cash Advance Program Before? Any State / Federal Liens against Owner(s)? Have You or Business Ever Declared Bankruptcy? Are any Lawsuits or Judgments Pending? TRADE REFERENCE (1) Business Name YES NO YES NO YES NO YES NO YES NO If Yes, Details : Contact, Account Number or Fax Number Phone Number If Yes, Details: If Yes, Details: If Yes, Company: If Yes, Company: Balance:

TRADE REFERENCE (2) Business Name

Contact, Account Number or Fax Number

Phone Number

BUSINESS PROPERTY INFORMATION

Own/Lease Lease Start Date Lease Term Monthly Rent/Mtg Type of Building Square Footage (approx)

1. Application must include a copy of a voided check, each owners valid drivers license, and your valid business license. 2. Citiwide will conduct independent due diligence of each Merchant that desires financing from Citiwide, and Citiwide may deny financing to any applicant at its sole discretion. 3. Merchant acknowledges and agrees that a consumer or investigative report, including a credit check with recognized credit reporting agency(s), may be conducted in connection with this Application. Merchant hereby authorizes Citiwide and its agents and representatives to (i) initiate such reports, investigations and/or credit checks, (ii) investigate any statements made or data received from or about Merchant and/or its owners/share holders, and (iii) contact any references given by Merchant or its owners/shareholders. 4. Application must include your last 6-12 complete, consecutive credit card statements, and 3 months bank statements.

Owner (1) Signature

Date

Owner (2) Signature

Date