ISO Application

Business Information

First Name *

Last Name *

Email *

Legal Business Name *

DBA Name

Website

Physical Address *

Apt, Floor, Suite, etc *

City *

State *

Zip Code *

Business Start Date *

Business Phone Number *

Fax Number

Federal Tax ID / EIN *

# of locations *

# of sales agents *

Do you currently sell merchant cash advance? *
—Please choose an option—YesNo

How did you hear about us?
—Please choose an option—Internet SearchA ColleagueI don't rememberEmailOther

Are you interested in white labeling our services? *
—Please choose an option—YesNo

Are you interested in syndicating on deals? *
—Please choose an option—YesNo

Principal Ownership Information

Principal Owner Name *

Ownership Percentage *

Are you a US citizen? *
—Please choose an option—YesNo

Cell Number *

Date of Birth *

Social Security Number *

Home Address *

Apt, Floor, Suite, etc *

City *

State *

Zip Code *

Bank and Contact Information

Name *

Email *

Bank Name *

Account Number*

Routing Number*

Voided Business Check *

Copy of Principal Owner's Drivers License *

Authorization to Disclose/Verify Information

As part of the application process, Premium Merchant Funding may verify the information contained in my/our enrollment application by completing a background check. By signing below, you are authorizing Company to perform this check and create an affiliate partnership in you/your business entity's name.

Name *

Signature *

Date*