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Request Advance


Merchant Advance Request Form: 

 

  1. Complete the form below.
  2. Call 1.800.208.FDIS with any questions


Complete this form and an authorized agent will contact you and guide you through the process of setting up your Merchant Advance. *Please make sure all information requested is accurate to expedite your request. 

I Need to Contact: *
Business Legal Name: *
Business DBA Name: *
Feredal ID #: *
Type of Business: *
Other Mercant Advances: * Yes
No
State of Incorporation: *
Use of Proceeds: *
Business Physical Street Address: *
City: *
State: *
Zip Code: *
Same as above: * Yes
No
Billing Street Address (If different):
City:
State:
Zip Code:
Physical Location Phone #: *
Preferred Contact Phone #: *
Preffered Fax #: *
Gross Annual Sales (Previous Year 1040): *
Date started processing credit cards: *
Are you a new owner: * Yes
No
Owner / Officer Name: *
Job Title: *
Ownership %: *
Date of birth: *
SS #: *
Email: *
Home Phone #: *
Cell Phone #: *
Home Street Address: *
City: *
State: *
Zip Code: *
Trade Reference #1 - Co. Name: *
Contact Name: *
Phone #: *
Fax #: *
Trade Reference #2 - Co. Name: *
Contact Name: *
Phone #: *
Fax #: *
Trade Reference #3 Co - Name: *
Contact Name: *
Phone #: *
Fax #: *
Business Location: *
Mortgage: * Yes
No
Mortgage Company (Complete the following):
Phone #:
Fax #:
Landlord: * Yes
No
Landlord Name (Complete the Following):
Lease start date:
Lease Term:
Monthly rent amount $:
Contact Name:
Phone #:
Fax #:
Bank Name: *
Phone #: *
Fax #: *
Comments:
Sales Representative:
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