1. Decimal Factor, Inc. Administrative Form
Merchant Information
Type of Entity (check one)_corporation_limited liability company_partnership_limited partnership_limited liability partnership_sole proprietorship
Merchants Legal Name: D/B/A: Federal ID
Physical Address: City, State Zip: Use of Proceeds
State of Incorporation/Organization Specific Type of Date business started (mm/yy) Length of Ownership Requested Amount
Business
Position: Phone(area code + number): Fax (area code + number):
E-mail address:
Website address : Describe Specific Types of Product/Service Sold :
Principal No. 1 Percentage (100%)of Ownership
Name: Social Security Number:
Date of Birth: Position OWNER Home Phone: Cell Phone:
Residence Address City, State Zip How long at home address? How long at Previous address?
Principal No. 2 Percentage (______%)of Ownership
Name: Social Security Number:
Date of Birth: Position OWNER Home Phone: Cell Phone:
Residence Address City, State Zip How long at home address? How long at Previous address?
Trade References
Company: Contact Name: Phone Number:
Company:
Contact Name: Phone Number:
Company: Contact Name: Phone Number:
Is your business for sale? Have you ever filed for bankruptcy? Have you had a previous cash advance? If YES, How much
current balance left to be paid?
Own Lease: Time Remaining
Landlord/Mortgage Company: Contact Name: Phone Number:
on the lease:
Bank Information
Bank name: Phone Number: Address: City : State: Zip:
Transit # (ABA Routing): Account #: Personel Bank:
Visa / MasterCard Information
Yearly Gross Sales (Including cash, Monthly Visa/Mastercard
Average Ticket : Annual Visa/MC Sales:
check, and all credit cards) : Average:
Merchant #
Current Processor Name: Time with current Processor: Terminal Type: # of CC Terminals:
Workingcapital4U is a marketing division of Decimal Factor Inc. Applicant authorizes Decimal Factor Inc. its assigns, agents, bank
or financial institutions to obtainan investigative or Consumer report from a credit bureau or a credit agency and to investigate
thereferences given on any other statement or data obtained from applicant. .
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