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24th June 2021

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Application for merchants

Legal/Corporate Name

DBA

Physical Address

City

State

Zip

Telephone

Fax

Federal Tax ID

Date Business Started

Length of Ownership

Website

E-mail Address

Type of Entity (circle one)

Sole PropiertorshipPartnershipCorporationLLCOther

Type of Business (circle all that apply)

RetailMO/TOWholesaleRestaurantSupermarketOther

Product/Service Sold

MERCHANT/OWNER INFORMATION

Corporate Officer/Owner Name

Title

Ownership %

Home address

City

State

Zip

SSN

Date of Birth

Home

Cell

PARTNER INFORMATION

Partner Name

Title

Ownership %

Home address

City

State

Zip

SSN

Date of Birth

Home

Cell

BUSINESS PROPERTY INFORMATION

Business Landlord or Business Mortgage Bank

Contact Name and/or Account

Phone

BUSINESS TRADE REFERENCES

(Please list at least 3 trade suppliers. Please attach any additional references on a separate page.)

Business Name

Contact Name and/or Account

Phone

Business Name

Contact Name and/or Account

Phone

Business Name

Contact Name and/or Account

Phone

Business Name

Contact Name and/or Account

Phone

AGENT USE ONLY

Processing Company

Number of Terminals

Terminal Type

Requested Advance Amount

Requested Daily Withholding

Monthly Volume

Prior/Current Cash Advance Company (if applicable)

Balance

Applicant authorizes Yellowstone Capital its assigns, agents, banks or financial institutions to obtain an investigative or consumer report
from a credit bureau or a credit agency and to investigate the references given on any other statement or data obtained from applicant.

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