Merchant Application BUSINESS DETAILS Legal Name Address Phone Website DBA Fed Tax Id (##-#######) Business Start Date City, State, Zip Company Type C Corp LLC S Corp Sole Prop Partnership Merchant Type Retail Restaurant Service Internet Business Location Store Front Office Home Other Products/Services Sold ADDRESS City State/Province AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX VI UT VT VA WA WV WI WY Postal Code Country United States Of America Owner# 1/Principal Information Name Address City, State Zip Home Phone Mobile Email % of Ownership Date of Birth SSN# Owner# 2/Principal Information Name Address City, State Zip Home Phone Mobile Email % of Ownership Date of Birth SSN# Signature ❌ Files Please upload your last 3 months business bank statements Please add your last 3 months credit card processing statements (Optional) Credit Authorization I authorize By signing below, the Merchant and its Owners / Principals: (1) certify that all information and documents submitted in connection with this application is true, correct and complete; (2) authorize The Belmont Franklin Group its agents, partners, and lenders, to receive credit reports and any other information regarding the Merchant and its Owners and Principals from third parties, to verify any information provided on the application; (3) to receive an occasional promotion or offer by email or fax. (4) By signing up via this form, I agree to get text and email messages from The Belmont Franklin Group relating to my application and may receive solicitations from time to time. Message frequency varies. Message & data rates may apply. Reply STOP to opt-out at any time or HELP for more information. Submit Application
