Sales Representative Rep

Merchant Pre-Qualification Form

Business Legal Name: Business DBA Name:

Type of Business

Entity (Check One)

Corporation Limited Liability

Company

Partnership Limited

Partnership

Limited Liability

Partnership

Sole Proprietor

Does the Merchant have any other businesses

with current AdvanceMe contracts? Check one

YES NO

State of Incorporation: Use of Proceeds:

Physical Street Address: City: State: Zip Code:

Billing Street Address

(If different than above):

City: State: Zip Code:

Physical Location Phone #: Billing Location Phone #: Preferred Contact Phone #: Industry Type: (SIC Code or Description) Rented Mortgaged Amount:

Gross Annual Sales (Previous year’s Tax return): : Average Monthly Credit Card Volume: Last Month: Two Months Ago: Three Months Ago: Four Months Ago: List the total

VISA/MasterCard

processing volumes

from previous four

months:

$ # Tickets: $ # Tickets: $ # Tickets: $ # Tickets: Owner/Officer Primary Contact Job Title:

Last Name: First Name: SS#: Date of Birth: Home Phone: Street Address: City: State: Zip Code:

Authorizations

offer certain financial products

to businesses, and certain in connection therewith, including gathering information from applicants and third parties, including credit bureaus, and transmitting such information to By signing below, the above listed business (“Merchant”) and Owner(s) / Officer(s) (collectively hereafter

“Applicants”) request that evaluate whether Merchant pre-qualifies for the financial product(s) requested by Merchant, as well as any other financial products offered by for which the Merchant pre-qualifies. Applicants represent that the information contained on this Merchant Pre- Qualification Form and the statements provided to are true and correct, and Applicants will immediately notify C of any financial change in Applicants. Applicants hereby authorize C as agent (1) to obtain on any of the Applicants any investigative reports, credit reports

(business and personal), statements from creditors or financial institutions, verification of information provided by any of the Applicants, or any other information (collectively “Applicant Information”) that deem necessary or desirable in connection with the evaluations and (2) to transmit this Merchant Pre-Qualification Form, statements and Applicant Information to one or . Applicants also here authorize

, acting on its own behalf, to take any one or more of the actions described in part (1) of the immediately preceding sentence. Applicants hereby authorize the release by any creditor or financial institution to C of any information relating to any of the Applicants. Applicants waive and release any claims against C or any creditor, credit bureau or financial institution arising from any act or omission relating to the obtaining or release of information sought by C . Applicants agree that any pre-qualified terms communicated by or on behalf of confidential and may not be disclosed to third parties (other than to Applicants' legal or financial advisors or as required by law), except at express, written direction

Owner / Officer’s Name: (Print)

Owner / Officer’s Signature: X Date:

Sales Information (To be completed by Sales Representative) Sales Rep #: Sales Rep Name : Sales Rep Contact #: Additional Contact #: E-Mail Address :

Requested working capital amount: $ Merchant email address: Note:

Masoumeh Kazemipour (Jul 26, 2022 12:45 PDT)

834470410 83-4397005

83-4397005

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