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Merchant Pre-Qualification Form
Business Legal Name:
Business DBA Name:
Type of Business Entity:
Corporation
Ltd. Partnership
LLC
LLP
Partnership
Sole Proprietor
Primary Business Structure: (Check All That Apply):
Home-Based Business
E-Commerce
Franchise
None of the Above
Does the Merchant have any open MCA or loan accounts?
Yes
No
Federal Tax ID:
Industry Type (Describe):
State of Incorporation:
Use of Proceeds:
Business start date under current Ownership:
Merchant Email Address:
Physical Street Address:
City:
State/Province:
ZIP / Postal Code:
Physical Location Phone #:
Billing Street Address (If different than above):
City:
State/Province:
ZIP / Postal Code:
Preferred Contact Phone #:
Gross Annual Sales (from previous year's tax return):
Owner/Officer (Primary Contact)
Job Title:
First Name
Last Name
SS#:
Home Phone:
Date of Birth:
Street Address:
City
State/Province
ZIP / Postal Code
AUTHORIZATIONS
By signing below, each of the above listed business and business owner/officer (individually and collectively, "you") authorize [BLVD funding] 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 Merchant Cash Advance transactions, including without limitation the application therefor (collectively, "Transactions") to obtain consumer or personal, business and investigative 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 may also authorize BLVD funding 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 BLVD funding and to each of the Recipients, on its own behalf.
Owner / Officer's Signature (Image):
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Owner / Officer's Name (Print):
Owner / Officer's Name (Print):
Merchant Cell Phone #:
Merchant Fax #:
Merchant Web Address:
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