Zoho Sign Document ID: 322E6627-ZLPXJ34ZRQIOQ70ET84PKISO7LRNRFT_JYLRDOKV98Q
Revenue Boost Fronter Name: 9600 NW 25th Street Doral
Fl. 33172
Merchant Pre-Qualification Form
Business Legal Name: Business DBA Name:
Nolan's Flowers, Inc.
Business start date MM/DD/YR: Industry Type: Type of Business Entity:
09/01/1966 Retail Florist Retail Florist = Flowers and Plants
Federal Tax Id: Does the Merchant have any open MCA or loan accounts?
04-2400871 Yes No
Current Credit Card Processor: State of Incorporation: Primary Business Structure: (Check All That Apply):
MA Home-Based Business Franchise E-Commerce None of the Above
Use of Proceeds: Gross Annual Sales (from previous year’s Avg. Transaction Avg. Monthly Volume: Physical Location Phone #:
Tax return): Amount:
1,000,000
Upgrade inside store, Downpayment for a van and delivery ????? $75,000
Physical Street Address: City: State: Zip code: Business Location(s):
MA
258 Commonwealth Avenue Attleboro Falls 02763 Attleboro Falls, MA
Billing Street Address (If different than above): Preferred Contact Phone #: Merchant Email Address:
P.O. Box 2696 508-695-7083 Nolansflowers@aol.com
Owner 1/Officer 1 Primary Contact Job Title:
First Name: Last Name: SS#: Date of Birth: Home Phone:
Donald McClain 028-40-9407 03/08/1958 508-369-3582
Street address City: State: Zip code:
Owner 2/Officer 2 Primary Contact Job Title:
First Name: Last Name: SS#: Date of Birth: Home Phone:
Street address City: State: Zip code:
AUTHORIZATIONS By signing below, each of the above listed business and business owner/officer (individually and collectively, “you”) Revenue Boost (RB) and each of its representatives, successors, assigns and
designees (“Recipients”) that may be involved with or acquire commercial loans having daily repayment features or purchases of future receivables including Payment Rights and Purchase Sale transactions,
including without limitation the application therefor (collectively, “Transactions”) to obtain consumer or personal, business and investigative or credit reports and other information about you, including credit card
processor statements and bank statements, from one or more consumer reporting agencies, such as TransUnion, Experian and Equifax, and from other credit bureaus, banks, creditors and other third parties. You
also authorize Revenue Boost to transmit this application form, along with any of the foregoing information obtained in connection with this application, to any or all of the Recipients for the foregoing purposes.
You also consent to the release, by any creditor or financial institution, of any information relating to any of you, to Revenue Boost and to each of the Recipients, on its own behalf.” Owner(s) and business (“you”)
understand that if this business credit request is approved, your payment obligations can be made through ACH debits by lender/purchaser or its designee from your bank account. By signing below, you hereby
authorize lender/purchaser or its designee to initiate an ACH test debit from the bank account designated below to confirm that if this credit request is approved, payment processing will proceed as agreed. The
test debit will be in a random amount but in no event more than $1.00
Owner 1/ Officer’s Signature: X _____________________________
Donald McClain
Owner 1/ Officer’s Name: (Print) _____________________________ Jun 17 2024 09:12 EDT
Date:________________________
Owner 2/ Officer’s Signature: X _____________________________
Owner 2/ Officer’s Name: (Print) _____________________________ Date:________________________
Merchant Cell Phone#: Merchant Fax#: Merchant Web Address:
Landlord Name: Landlord Contact#: Is Your Business Seasonal? Y N
Any Judgments/Liens Any Open Bankruptcies? Y N ✔ If yes, what are the peak months?) Feb-MAY- DEC
Second owner name and % of ownership:
Business Trade Reference #1: Phone #:
Business Trade Reference #2: Phone #:
