1. Business DBA Name:Business Legal Name:
State Of Incorporation: Use Of Proceeds:
City: Zip Code:
Zip Code:
Billing Location Phone #: Fax # :
State:
State:
Website Address:
If yes, what are the Peak Months
Any Judgments/
Liens?
Billing Street Address
(If different than above):
Gross Annual Sales (Previous year’s Tax
return):
Date the Business first
processed Credit Cards
under current Ownership/
Business Start Date:
Current Credit Card Processor:
Owner/Officer Primary Contact Job Title: Cell Phone:
Last Name: First Name: SS#: Date Of Birth:
Home Phone:
City: State: Zip Code:Street Address:
Second Owner
(If Any)
First Name: Last Name: Percentages:
Business Trade Reference #1: Phone #:
Business Trade Reference #2: Phone #:
Business Trade Reference #3: Phone #:
Owner / Officer’s Name: (Print) _________________________
Owner / Officer’s Signature: _____________________________________
Date: ______________________
Merchant Pre-Qualification Form
Federal Tax Id:
Office/Bldg: Ownership: Loan Use For ?:
Average Monthly
Credit Card Volume:
Landlord Full Name:
Is Business Seasonal?
Industry Type: (SIC Code or Description):
Physical Location Phone #:
Any Open Bankruptcies?
Does the Merchant have any other
businesses with open contracts for working
capital:
Physical Street Address:
Type of Business
Entity ? (Select )
By signing below, Merchant and its owners/principals: (1) certify that all information and documents submitted in connection
with this Application are true, correct, and complete; and (2) authorize Klein Capital and its partner H&H Consultants, its
partners, affiliates, and lenders to receive credit reports and any other information regarding the Merchant and its owners and
principals to verify any information provided on the application.
Employee ID:
City:
Landlord Phone #
Preferred Contact Phone # :
Desired Loan Amount ?:
Other:
O4411-15
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Fax: (888) 651-6706 Email: PreQual@KleinCapital.net
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