Merchant Money

Step 1

Agent ID:

click here if you currently process with
Merchant Data Systems and are applying
for a cash advance only.

BUSINESS NAME(s)
Business Legal Name:
Business Name / DBA Name:
Mailing Address:
Address 2:
Address 3:
City:
State:
Zip:
Contact Name:
E-Mail Address:
Phone Number:
Fax Number:
Business Address (If different):
Address 2:
Address 3:
City:
State:
Zip:
Contact Name:
Phone Number:
Fax Number:
OWNERSHIP INFORMATION
Ownership Type:
if other:
Federal Tax ID #: no spaces or dashes
Owner 1/Partner/Officer Name:
Title in Business:
Equity Ownership:	%
Social Security #: 9 digits, no spaces or dashes
Date of Birth (mm/dd/yyyy):
Home Address:
Address 2:
City:
State:
Zip:
Phone Number:
Owner 2/Partner/Officer Name:
Title in Business:
Equity Ownership:	%
Social Security #: 9 digits, no spaces or dashes
Date of Birth (mm/dd/yyyy):
Home Address:
Address 2:
City:
State:
Zip:
Phone Number:

Red Items Are Required