Business Legal Name (“Merchant”): *

Business DBA Name:

Address: *

Suite/Floor:

City: *

State: *

Zip: *

Phone: *

Phone:

(###)

###

####

Mobile:

(###)

###

####

Fax:

(###)

###

####

Website:

http://

Email: *

Legal Entity: *

Employer Tax ID #:

Business Type:

Date Business Started: *

Date Business Started:

YYYY

Business Location:

If Corp./LLC, State Where Incorporated/Formed:

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:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone: *

Phone:

(###)

###

####

Email: *

% of Ownership: *

Date of birth: *

Date of birth:

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:

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.