Full Application Form

Sales Method

Retail Swiped

KEYED

ECOMM

MOTO

Fee Schedule

Visa/MasterCard/Discover/AXP Qualified Credit Card Discount Rate(for Tiered/Flat) %

Visa/MasterCard/Discover/AXP Qualified Credit Card Pass Thru I/C Plus

Qualified Check Card Discount Rate (for Tiered/Flat)

Qualified Check Card PassThru I/C Plus

Visa/MasterCard/Discover/AXP

Authorization Fee

Monthly Program Fee "Cash Discount"

Customer Service Fee

Monthly Minimum Fee

PIN Debit Transaction Fee

Batch Fee

Amex OPT Blue Qualified Rate

Amex OPT Blue Mid Qual

Amex OPT Blue Non Qual

Amex OPT Blue Pass Thru I/C Plus

Amex ESA #

AVS Transaction Fee

EBT Transaction Fee

EBT Account#

Amex Processing Fee

Other Fee

3 Tier Pricing Visa/MC/Disc/AXP Mid Qual

3 Tier Pricing Visa/MC/Disc/AXP Non Qual

Chargeback Fee

ACH Retrieval Fee

Additional Guarantors

Are there any additional guarantors?

Yes No

First Name

Middle Name

Last Name

Phone #

Cell

SSN

Date Of Birth

Marital Status?

Address

City

State

Zip

Citizenship

U.S. Citizen Perm Resident Alien Non-Perm Resident Alien

Guarantor Notes

First Name

Middle Name

Last Name

Phone #

Cell

SSN

Date Of Birth

Marital Status?

Address

City

State

Zip

Citizenship

U.S. Citizen Perm Resident Alien Non-Perm Resident Alien

Guarantor Notes

General Guarantor Notes

Applicant Experience

Does borrower have Fix & Flip or Buy & Hold experience?

Yes No

# of years of experience?

# of properties completed in last 36 months

List 3 examples of past deals:

Property Type
Purchase date

Purchase Price

Amount Financed

Rehab Budget

Entity Name

Ownership %

Exit

Sale Price

Sale Date

Address
City
State
Zip

Outcome/Profit

Upload HUD

Property Type
Purchase date

Purchase Price

Amount Financed

Rehab Budget

Entity Name

Ownership %

Exit Monthly Rent

Address
City
State
Zip

Upload HUD

Property Type
Purchase date

Purchase Price

Amount Financed

Rehab Budget

Entity Name

Ownership %

Exit Monthly Rent

Address
City
State
Zip

Upload HUD

Does borrower have ground up construction experience?

Yes No

# of years experience?

# of properties completed in last 36 months

List 3 examples of past deals:

Property Type

Purchase date

Purchase Price

Amount Financed

Rehab Budget

Entity Name

Ownership %

Exit

Monthly Rent

Sale Price

Sale Date

Borrower or Applicant Info

Co-Applicant Information

Business Entity

Sales Method

Fee Schedule

Equipment Info

Additional Guarantors

HMDA - (Borrower)

HMDA - (Co-Borrower)

Applicant Background

Co-Applicant Background

Applicant Experience