Isaac D.
Stern ISO # 11374P
P. 866-231-8707
F. 866-422-5562
BUSINESS INFORMATION
Legal/Corporate Name: DBA:
Physical Address: City: State: Zip:
Telephone #: Fax #: Federal Tax ID:
Date Business Started: Length of Ownership: Website:
Type of Entity (circle one): Email Address:
Sole Proprietorship Partnership Corporation LLC Other
Type of Business (circle all that apply): Product/Service Sold:
Retail MO/TO Wholesale Restaurant Supermarket Other
MERCHANT/OWNER INFORMATION
Corporate Officer/Owner Name: Title: Ownership %:
Home Address: City: State: Zip:
SSN: Date of Birth: Home #: Cell #:
PARTNER INFORMATION
Partner Name: Title: Ownership %:
Home Address: City: State: Zip:
SSN: Date of Birth: Home #: Cell #:
BUSINESS PROPERTY INFORMATION
Business Landlord or Business Mortgage Bank: Contact Name and/or Account #: Phone #:
BUSINESS TRADE REFERENCES
(Please list at least 3 trade suppliers. Please attach any additional references on a separate page.)
Business Name: Contact Name and/or Account #: Phone #:
Business Name: Contact Name and/or Account #: Phone #:
Business Name: Contact Name and/or Account #: Phone #:
Business Name: Contact Name and/or Account #: Phone #:
AGENT USE ONLY
Processing Company: Number of Terminals: Terminal Type
Requested Advance Amount: Requested Daily Withholding: Monthly Volume:
Prior/Current Cash Advance Company (if applicable): Balance:
Applicant authorizes 2nd Source its assigns, agents, banks or financial institutions to obtain an investigative or consumer report from a credit
bureau or a credit agency and to investigate the references given on any other statement or data obtained from applicant.
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Applicant’s Signature Date