Payment processing form

1
Company Information
2
Business Information
3
Financial Statements
4
Ownership Info – Applicant 1
5
Ownership Info – Applicant 2
6
Signature & Agreement
Legal / Corporate Name*
Doing Business As (optional)
Company Address*
Mailing/Registered Address (if different)
Company Phone *
Company Fax (optional)
Company Email*
Website (optional)
Business Start Date *
Federal Tax ID / EIN *
State of Incorporation *
Company Type *
Product or Service Sold / Business Description*
What Industry Are You In? *
Number of Owners *
Gross Monthly Revenue *
Gross Annual Revenue *
Average Monthly Credit Card Revenue (optional)
Average Ticket Size
High Ticket Value
Current Processor (optional)
Terminal
POS System
Version
Gateway
Upload Bank Statement – Month 1
Upto 4 PDF files only
Upload Bank Statement – Month 2
Upto 4 PDF files only
Upload Bank Statement – Month 3
Upto 4 PDF files only
Upload Bank Statement – Month 4 (Optional)
Upto 4 PDF files only
Upload Recent Credit Card Statement (optional, only required for California)
Upto 4 PDF files only
First Name *
Last Name *
Home Address (full address) *
Email Address *
Home Phone (optional)
Mobile Phone *
Company Title
FICO Score *
Date of Birth*
Social Security Number *
Ownership Length *
Ownership Percentage *
(Complete this section only if the company has multiple owners)
First Name
Last Name
Home Address (full address)
Email Address
Home Phone (optional)
Mobile Phone
Company Title
FICO Score
Date of Birth
Social Security Number
Ownership Length *
Ownership Percentage
Applicant 1 Signature
Date
Applicant 2 Signature (optional)
Date

By signing above, each of the above listed business and business owners/officers (individually and collectively, "you") authorize Linvera Funding LLC and each of its representatives, successors, assigns, designees and third-party funding partners, which includes lenders and other finance providers with whom Linvera has, or may in the future enter into, commercial-brokerage-financing relationships ("Recipients"):

  1. 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;
  2. to obtain the release, by any creditor or financial institution, of any information relating to any of you, to any Recipients;
  3. to transmit this application form, along with any of the foregoing information obtained in connection with this application, to any or all Recipients for the foregoing purposes; and
  4. to contact you via e-mail, call and/or text-message at the e-mail address and/or phone number provided above, or at any e-mail address and/or phone number reasonably identified as belonging to you, including wireless numbers (if applicable), using an automated telephone dialing system or other similar system with respect to this application, future-related commercial-financing opportunities and/or other lawful telemarketing purposes (the consents provided in this subsection
  5. the "Communications Consent".

By signing above, each of the above listed business and business owners/officers (individually and collectively, "you") authorize Linvera Funding LLC and each of its representatives, successors, assigns, designees and third-party funding partners, which includes lenders and other finance providers with whom Linvera has, or may in the future enter into, commercial-brokerage-financing relationships ("Recipients"):

Have you spoken to a Funding Specialist here at Linvera?
Account Representative Name (optional)
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