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BUSINESS INFORMATION

Business Name:*
Business Partner Name:
DBA:
Address:*
Email:*
Phone:*
Federal Tax ID:*
Business start date under current ownership:*
State of Incorporation or Organization:*
Additional Information:*
Add more informationNo additional information
Website :
Type of Entity:
Type of Business:
Products/Services Sold:
Gross Annual Sales (from previous year tax return):
Last 4 months bank deposits:
How many negative balance days have you had over the past 4 months?
Last 4 months Visa/MC volume & ticket count:
Have you previously filed for bankruptcy?
If yes, when?
Do you have any open merchant cash advance
or business loan accounts?*
Please list your current advance provider/s:*
Current Balance::*

MERCHANT/OWNER INFORMATION

Corporate Officer/Owner Name : *
Title :
Ownership % :
Home Address:*
SSN:*
FICO:*
Date of Birth::*
Cell Phone:*

PARTNER INFORMATION

Business Trade References:*
No References ListedAdd references
Business Name1:*
Phone:*
Cell Phone:*
Business Name2:*
Phone:*
Cell Phone:*
Business Name3:*
Phone:*
Cell Phone:*

Bank Statement 1:
Bank Statement 2:
Bank Statement 3:
Bank Statement 4:
Do you process Credit Cards?
NoYes
Card Statement 1:
Card Statement 2:
Card Statement 3:
Additional Documents:

Use this field to upload additional information such as tax returns, driver's license, void checks, etc.

By signing below, each of the above listed business and business owner/officer (individually and collectively, “you”) authorize eWallet Inc. and each of its representatives, successors, assigns and designees (“Recipients”) that may be involved with or acquire commercial loans having daily repayment features or purchases of future receivables including Merchant Cash Advance transactions, including without limitation the application therefor (collectively, “Transactions”) to obtain consumer or personal, business and investigative reports and other information about you, including credit card processor statements and bank statements, from one or more consumer reporting agencies, such as TransUnion, Experian and Equifax, and from other credit bureaus, banks, creditors and other third parties. You also authorize eWallet Inc. to transmit this application form, along with any of the foregoing information obtained in connection with this application, to any or all of the Recipients for the foregoing purposes. You also consent to the release, by any creditor or financial institution, of any information relating to any of you, to eWallet Inc. and to each of the Recipients, on its own behalf. You also authorize eWallet Inc. and each of its Recipients to contact you via text message, automated call or email message at the contact information listed above.


Date:

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Digital signature:

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