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The Smart Choice For Immediate Working CapitalSM

Easy Access to Cash

Call Today To Find Out How Much You Qualify For: MARTIN BUSS

800-450-0031 Ext 2370 (Toll Free)318-581-8398 (Direct Line)

mbuss@globalmerchantservices.com

Please fax the following along with your application:

Last 4 months of Visa/Master Card Statements.•_______________________________________•_______________________________________•

Merchant Information

Legal Business Name DBA Name Estimated Total Monthly Sales Time Remaining on Site Lease/Mort.

Street Address % Ownership Type of Business Landlord/Agent Name

City Federal Tax ID Number (9 Digits) Years in Business Landlord/Agent Phone

State Zip Intended Use of Cash Advance Number of Locations Name of bank (Business)

Business Phone Requested Amount Is your business for sale? Have you had a previous cash advance?

Business Fax Email Have you ever filed for bankruptcy? Any federal or state tax liens?

Current Processor Number of Terminals at Location

Merchant Account Number Time with Current Processor

Terminal Type Average Monthly Volume – Visa/MC

Credit Card Processor Information

Merchant ID Partner Name/ID

F O R P A R T N E R U S E O N L Y F O R P A R T N E R U S E O N L Y F O R P A R T N E R U S E O N L Y

u u u u 3 Minute Merchant Application Fax To: 1-800-209-0611

Principal Owner Name Social Security Number

Home Street Address Date of Birth (00/00/0000)

City % Ownership?

State Zip How long at home address?

Home Phone How long at previous address?

Mobile Phone Estimated Current Annual Income

Name of Bank (Personal)

Principal Owner Information

Principal Owner Name Social Security Number

Home Street Address Date of Birth (00/00/0000)

City % Ownership?

State Zip How long at home address?

Home Phone How long at previous address?

Mobile Phone Estimated Current Annual Income

Name of Bank (Personal)

Principal Owner Information

Rev. 9.4.16

nono

no no

Partner Sales Person Name Partner Phone

By signing this Agreement, the Business and Principal Owner(s) hereby authorize inquiry into their credit and financial information, including, but not limited to, consumer reports and credit bureaus, and criminal and civil matters. Without limiting the generality of the preceding sentence, the Merchant hereby authorizes our company to obtain consumer and/or investigative reports from one or more consumer reporting agencies about Merchant. By signing this Agreement, the Merchant hereby authorizes us obtain the twelve most recent monthly reports (If Applicable) detailing Merchant’s credit card processing activity from its card processor or any agent or other third party utilized by that processor to authorize, clear and/or settle credit card payments.

Merchant: _______________________________________________________________________ By: _______________________________________________________(signature)

Print Name: _________________________________________________ Title:___________________________________ Date: ________________________

Owner: _____________________________________________________ Print Name: _________________________________________ Date: _______________________(signature)