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Business Overview
References
Owner/Principal Info
Business Legal Name (“Merchant”):
*
Business DBA Name:
Address:
*
Suite/Floor:
City:
*
State:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
*
Phone:
*
(###)
###
####
Mobile:
(###)
###
####
Fax:
(###)
###
####
Website:
http://
Email:
*
Legal Entity:
*
Corp
Sole Prop
LLC
Partnership
Employer Tax ID #:
Business Type:
Date Business Started:
*
MM
DD
YYYY
Business Location:
Store Front
Office
Home
Other
If Corp./LLC, State Where Incorporated/Formed:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Average Gross Monthly Sales:
*
$
Products/Services Sold:
Business References
Trade Reference 1:
Name:
Phone:
(###)
###
####
Trade Reference 2:
Name:
Phone:
(###)
###
####
Trade reference 3:
Name
Phone:
(###)
###
####
Landlord/Mortgage Company Contact:
Name:
Phone:
(###)
###
####
Bank Reference:
Name:
Phone:
(###)
###
####
Rent/Mortgage Payment:
$
Owner/principal information
Name
*
Address:
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone:
*
(###)
###
####
Email:
*
% of Ownership:
*
Date of birth:
*
MM
DD
YYYY
SSN#:
*
Driver’s License #:
Name:
Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone:
(###)
###
####
Email:
% of Ownership:
Date of birth:
MM
DD
YYYY
SSN#:
Driver’s License #:
*
By checking this box and clicking “Submit” the Merchant and its owners / principals: (1) certify that all information and documents submitted in connection with this Application are true, correct and complete; and (2) authorize Azadian Group LLC, its agents, partners, assignees and affiliates to receive credit reports and any other information regarding the Merchant and its owners and principals from third parties to verify any information provided in the Application.
Thank you!