Application

Background

Legal Corporate Name:

Address:

Website:

Telephone #:

Fax #:

E-mail address:

State of Incorporation:

Years in Business:

Briefly Describe Your Business:

Purpose of Funding:

Sales Information

Total Annual Revenue: $

Amex %

Visa/MC %

Cash %

Invoiced %

Other %

Average % of Sales Charged Back: %

Average Ticket

# of locations

Ownership

Principal (1)

% of Ownership

Name

Address

Principal (2)

% of Ownership

Name

Address

The information contained in this credit application is provided to Credit Cash for the purpose of obtaining credit. The applicant understands that Credit Cash is relying on this information in deciding whether or not to extend credit to the applicant. The applicant represents and warrants that the information provided is correct. Credit Cash is authorized to make all inquires, including credit checks, to verify applicants’ credit worthiness.

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