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Call 855-850-2176 Please enable JavaScript in your browser to complete this form.1Basic Info2Business Funding 13Business Funding 24Merchant Processing5Business Info6SubmitName *FirstLastPhone # **only numbers (no spaces or special characters)Email *NextBusiness Funding 1What is your gross monthly revenue? *$1 - $10,000$10,000 - $25,000$25,000 - $50,000$50,000 - $100,000$100,000- $250,000$250,000- $500,000$500,000+Use of funds *Acquire a new businessBridge PaymentsHire New EmployeesPayrollPurchase Real EstateRemodelotherHow much do you need? *PreviousNextBusiness Funding 2Do you own Commercial Real Estate? *YesNoDo you have Accounts Receivable? *YesNoWhen do you need funding by? *ASAP1-3 days1 week1 monthPreviousNextMerchant ProcessingHow much monthly credit card sales volume? *$1-$10,000$10,000 - $25,000$25,000 - $50,000$50,000 -$100,000$100,000- $250,000$250,000- $500,000$500,000 +How much is your average transaction size? *$1-$25.00$25-$50$50-$100$100-$500$500-$1,000$1,000-$5,000$5,000+What type of equipment do you use? *POS Solution TerminalWhat POS do you use?NextBusiness Name (D.B.A) *Tax ID#*only numbers (no spaces or special characters)Social Security # (SSN)*A soft credit pull will be done. It will not show up or affect your credit score. (numbers only)Corporate Name (If Different)Address Line 1 *Address Line 1City *CityState *ALAKAZARCACZCOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVIVAWAWVWIWYZipcode *ZipcodeIndustry *AccountingAdoption AgencyAdult Content WebsitesAdult Day CareAdult Night ClubsAdult related businessAgricultureAirlinesAlcohol DistributionAnnual Membership ClubsApparelAppliance RepairAppraisal ServicesArchitectArt GalleryAssisted Living/Rehabilitation FacilityATM RentalsAttorneyAuction Houses/Auction BusinessesAutomotive DetailingAutomotive PartsAutomotive Rental (No Sales)Automotive RepairAutomotive Sales - NewAutomotive Sales - UsedAutomotive TowingAuto Sales & RepairAviationAwards & TrophiesBail BondsBakeriesBankingBarber ShopsBeauty pageant organizationsBenefit PackagesBiotechnologyBitCoinBlindsBoating ClubBoat RentalBoat SalesBook StoreBridal WearBrokerBusiness OpportunityBuyer Clubs/Financial AidCabinetryCampgroundCandy StoresCarpet CleaningCar WashCar WrappingCatering HallsCheck Cashing ServicesChemicalsChild CareChildren's ClothingChildren's ShoesChiropractorsChurch / TempleCigar ShopsCollection AgenciesCommodities BrokerCommunicationsComputer/Electronics RepairComputer Equipment SalesConcierge ServicesConstructionConstruction - General ContractorConstruction MaterialsConstruction - New HomeConsultingConvenience/General StoreCosmetics/PerfumesCosmetic SurgeryCounselingCountry ClubCoupon BooksCredit Card ProcessingCredit Protection/ConsolidationCustoms BrokerD.J. (Disc Jockey)Dairy Products StoresDance SchoolDebt ConsolidationDentistsDetective ServicesDiet ProgramsDisposal/Removal ServicesDistributing CenterDonationsDoor to Door SalesDriving SchoolDry Cleaning/LaundryeCommerce BusinessesEducationElectricianElectronicsEmbroidery & Screen PrintingEmergency/Sanitation ResponseEnergyEnergy SupplierEngineerEngineeringEntertainmentEnvironmentalEquipment FinancingEquipment RentalEquipment SalesEvent/Party PlannerEvent & Trade Show ServicesEvent MerchandisingExcavatingExterminatorEye DoctorsFacilities ManagmentFamily ClothingFarmingFence Installationfestivals & toursFilm ProductionFinancial ServicesFirearms/Hunting ShopFire Prevention/Sprinkler SystemsFitness Clubs / GymFitness ServicesFlooringFloralFood/Fruit/GourmetFood & BeverageFootwearFormal WearFortune tellersFundraisingFuneral HomeFuneral MemorialsFurniture StoresGamblingGamingGaming ExcursionsGas StationsGas Stations with Convenience StoreGovernmentGraphic DesignGun DealersHair/Nail/Skin CareHardwareHazardous Waste Removal/CleanupHealthcareHealth SpaHeating/Air HVACHigh Ticket ElectronicsHome Alarm InstallationHome InspectionHomeopathic Remedies/ DrugsHookah BarHorse TrainerHospitalityHousing related industryHunting ExcursionsImport/ExportIndustrialInsulationInsuranceInterior Design/DecoratingInternet and Website ServicesInternet Tobacco, Firearms & AlcoholInvestigatorInvestment opportunities / adviceJanitorialJewelryJuniors ClothingKiosksLandscapingLaw FirmLegal ServicesLimousine/Transportation ServicesLiquor StoresLivestockLodging Hotel/MotelLoggingLounges / Drinking PlacesLumberMachineryManagement CompanyManufacturingMarijuanaMarinasMarketingMasonry and Other StoneworkMattress StoreMeat/SeafoodMediaMedical DoctorMedical SuppliesMEDICAL TRANSPORTATIONMen's ClothingMen & Women ClothingMen & Women ShoesMental HealthMiningModeling agenciesMonuments and/or MemorialsMotorcycle SalesMovie TheatreMoving CompaniesMulti-level marketing/Pyramid SalesNewspaperNon Profit/CharityNutrition and WellnessOil & FuelOnline ElectronicsOnline PharmaciesOnline TravelOptical Center/Glasses/ContactsOpticiansOtherOther Misc RetailOutdoor ServicesPainterParking Service/LotParty RentalsParty SuppliesPawn ShopsPayroll ProcessingPet Boarding/Kennel/Pet DaycarePet Funeral ServicesPet GroomingPet MerchandisePharmaciesPhotographyPlumbingPool/Jacuzzi Sales & ServicesPrepaid Phone CardsPrinting/PublishingProduceProfessional ServicesProperty MaintenanceProperty ManagementProtective ServicesPsychics / AstrologersPublic RelationsQuick Service RestaurantReal EstateRecreationRecreation CampRecyclingRepair ServicesRepossession (Automobiles)ResearchRestaurantRestaurant NightclubsRestoration- CommercialRestoration- HomeRetailRetail BicyclesRoofingSalvageScreenprinting and EmbroiderySeminarsSeptic ManagementService Beauty Shops/beauticiansService IndustrySexual encounter firmsShipping BusinessesSocial ServicesSoftwareSpecialty Dept. StoreSpecialty Goods DeliverySpiritualSporting FacilitySporting GoodsSports AgentSports and Fitness Training/DevelopmentSports MemorabiliaSprinklersStaffingStockSupermarkets/GroceryTailor/SeamstressTanning SalonTattoo ParlorTaxidermyTax ServicesTechnologyTelecommunicationsTelemarketingTestingTicket AgenciesTileTime ShareTitle CompanyTransitional HousingTransportationTravel AccommodationsTravel AgentUtilitiesVacation or Resort Destination RetreatsVapor ShopVeterinarianWater TreatmentWeldingWholesaleWindowsWinery/BreweryZooEntity Type *LLCPartnershipInternational org.Medical/Legal corp.Tax exemptGovernmentOptional File UploadsFile Upload for Month 1 of Merchant Processing Statements Click or drag a file to this area to upload. File Upload File Upload for Month 2 of Merchant Processing Statements Click or drag a file to this area to upload. Business Funding File UploadsMonth 1 Bank Statement (most recent) Click or drag a file to this area to upload. Month 2 Bank Statement Click or drag a file to this area to upload. Month 3 Bank Statement Click or drag a file to this area to upload. NextUpdating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.Terms & Conditions *I consent to receive emails, phone calls and/or text messages, including autodialed and pre-recorded calls, for marketing purposes, from Biz-Pay and its participating partners at the phone number and email address I provided. I acknowledge that consent is not a condition of purchase and that telephone calls to and from Biz-Pay or its partners may be recorded. Message and data rates may apply. I understand I may opt out at any time. I acknowledge that I have read the Credit Gathering Authorization terms as well as the terms and privacy of this website.PreviousSubmit!
