03-2015 merchant loan application page 1

Small Business Consulting www.dan-norwood.com 866-200-2352 Dan Norwood [email protected] 714-618-4010 [email protected] www.crosslateralgolf.com Business Legal Name Business Structure ___ Home Based ___ Franchise ___ E-Commerce ___ NA Type of Business ___ Sole Proprietor ___ Partnership ___ Corporation ___ LLC ___ LLP Federal ID # Loan Amount State ID # Workers Comp Carrier # of Employees # of Locations Physical Phone Cell Phone Other Contact # State of Corporation Length of Ownership How many Principals Gross Monthly Sales Average Transaction Amount Gross Annual Sales (Prior yr tax return) # of banks deposits (90 days) # of returned check fees Industry Type SIC or Description Average Depsosits 2 months Average Deposits 4 months Annual Credit Card Sales List of total credit card volume Average Monthly Credit Card Volume # of days with a negative balance Average Deposits 3 months Last month $_____________ # Tickets ______ Loan Terms Does Merchant have any open contracts for working capital ___ Yes ___ No Prior Month $_______________ # Tickets __________ Prior Month $_______________ # Tickets __________ Funding Information: Visa/MC Card Swipe _______% Manually Keyed ______% Phone/Mail Order ________% Internet ________% Other ________% Billing Address Location Physical Address Location Fax # Date Business Started Fico Primary Contact Net Worth Principal/s Renting or Leasing Business Property Landlord Contact Name Monthly Rent Square Footage Primary Contact Number Job Title Fico Primary Contact Net Worth Principal/s Net Worth Principal landlord Phone #/Landlord Principal First Name SS # Date of Birth United States Citizen ___Yes ___No Legal Alient ___Yes ____ How long Business Bank Phone Number Fax Number Business Bank Phone Number Fax Number Personal Bank Phone Number Fax Number Trade References Business Name Phone Number Fax Number Business Name Phone Number Fax Number Applicant authorizes Dan Norwood Enterprises to submit on applicants behalf the above transaction to a lender, lenders agent, it's assigns, banks or financial instution to obtain an investigative consumer and business report from a credit bureau or a credit agency and to fully investigate the references, trades, leases and any other pertinent information given on any othe statement of data obtained from applicant in order to process their application. This includes, but is not limited to speaking with landlords and management agencies Contact Contact Contact Contact Name Contact Name Owner/Officer Principals Address City State Zip Code County Business Credit Score Lease Start Date Lease Term Business Credit Score Net Woth Business Last Name Applicants Signature Date # # of credit card terminals terminal make and model Own or Lease Equipment Monthly Payment and term

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Page 1: 03-2015 Merchant Loan Application Page 1

Small Business Consulting www.dan-norwood.com 866-200-2352Dan Norwood [email protected] [email protected] www.crosslateralgolf.com

Business Legal NameBusiness Structure ___ Home Based ___ Franchise ___ E-Commerce ___ NA

Type of Business ___ Sole Proprietor ___ Partnership ___ Corporation ___ LLC ___ LLPFederal ID #

Loan Amount

State ID # Workers Comp Carrier

# of Employees # of Locations

Physical Phone Cell Phone Other Contact #

State of Corporation Length of Ownership How many Principals

Gross Monthly Sales Average Transaction Amount Gross Annual Sales (Prior yr tax return)

# of banks deposits (90 days) # of returned check fees Industry Type SIC or Description

Average Depsosits 2 months Average Deposits 4 months Annual Credit Card Sales

List of total credit card volume

Average Monthly Credit Card Volume

# of days with a negative balance

Average Deposits 3 months

Last month $_____________ # Tickets ______

Loan Terms Does Merchant have any open contracts forworking capital ___ Yes ___ No

Prior Month $_______________ # Tickets __________Prior Month $_______________ # Tickets __________

Business Credit Score

Funding Information: Visa/MC Card Swipe _______% Manually Keyed ______% Phone/Mail Order ________% Internet ________% Other ________%

Billing Address Location

Physical Address Location

Fax #

Date Business Started

Fico Primary Contact Net Worth Principal/s Renting or Leasing Business Property

Landlord Contact Name Monthly Rent Square Footage

Primary Contact Number Job Title

Fico Primary Contact Net Worth Principal/s

Net Worth Principal landlord Phone #/Landlord

Principal First Name SS # Date of Birth

United States Citizen ___Yes ___NoLegal Alient ___Yes ____ How long

Business Bank Phone Number Fax Number

Personal Bank Phone Number Fax Number

Trade ReferencesBusiness Name Phone Number Fax Number

Business Name Phone Number Fax Number

Applicant authorizes Dan Norwood Enterprises to submit on applicants behalf the above transaction to a lender, lenders agent, it's assigns, banks orfinancial instution to obtain an investigative consumer and business report from a credit bureau or a credit agency and to fully investigate thereferences, trades, leases and any other pertinent information given on any othe statement of data obtained from applicant in order to process theirapplication. This includes, but is not limited to speaking with landlords and management agencies

Contact

Contact Name

Owner/Officer

Principals Address City State Zip Code County

Business Credit Score

Lease Start Date Lease Term

Business Credit Score

Net Woth Business

Last Name

Applicants Signature Date

## of credit card terminals terminal make and model Own or Lease Equipment Monthly Payment and term

http://www.dan-norwood.com/