Intake Form – Services

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- Intake Form

Services

Business Funding
- Funding Qualification
Disclaimer
Free Smart Payment Device
Kiosk
Merchant Intake form
Privacy Policy
Prospect Intake Form
Referral Partner
Services
Terms of Use
Thank you
Zero Fee Processing
- Intake Form

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Merchant's Legal Name

Name *

First

Last

Layout

Phone *

Email *

Corporate Address

Address *

Address Line 1

City

State

Zip Code

DBA

Do your business work as a DBA? *

Yes
No

Layout

DBA Address

DBA City

DBA State

DBA Zip Code

Business Data

Layout

Owners Name *

Owner's Date of Birth *

Owner's Address *

Owner's City *

Owner's State *

Owner's Zip Code

Prior Bankruptcies *

Yes
No

Type of Ownership *

Incorporated State *

Business Start Date *

Monthly Card Sales

Average Ticket *

Highest Ticket *

Deposit Routing *

About your Business

Layout

Do you have a website? *

Yes
No

Website / URL

Is your business on social media? *

Yes, and active
Yes, but not active
No

Facebook Link

Business X Url

Business Instagram

Google My Business URL

Operations

Layout

Do you use a CRM? *

Yes
No
I am interested in getting a CRM

Do you currently use a payroll system? *

Yes
No

Does your business benefit from having immediate access to working capital through Cash Advance options? *

Yes
No

by Rich Ayala Consulting

Merchant's Legal Name

Corporate Address

DBA

Business Data

About your Business

Operations

Disclaimer

Terms of Use

Privacy Policy