1. Business Location

Company Name*

Contact Name*

Business Address*

City*

State*

Zip Code*

2. Operational Information

To be eligible for review, your business must process a minimum of $5,000 per month.

Operating Since*
---123456789101113141516171819202122232425262728293031 Day ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Month ---190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Year

Type of Business*
Please Select BusinessAccounting (CPA)AerospaceAgriculturalAircraftApparelArchitectAttorneyAutomotive PartsAutomotive ServiceBeverageBio-TechChiropractorComputer HardwareComputer SoftwareConstructionConsultingConsumer ProductsCouriers/MessengerDefenseDental TechnologyDentistDistributionEducation RelatedElectronicsEnergyEntertainmentEnvironmentalExisting TechnologyFederal GovernmentFilm, Play, VideoFinancial ServicesFitnessFood ServiceForestry and FishingFuneral HomeGamingGarmentGasoline StationHealth ProductsHealthcareHi-TechnologyImport/ExportIndustrial ProductsInsuranceInternet/Online ServicesLegal ProfessionLodgingManufacturingMarineMedia ProductionMedical (ologists)Medical (licensed)Medical (therapists)Medical TechnologyMobile Home ParksMorticianMunicipalNatural ResourcesNew TechnologyOptometryPharmacistPharmaceuticalsPiece GoodsPrintingPsychologistsPublishingReal Estate RelatedResortsRestaurantRetailSecuritySemi-ConductorsService RelatedSpace TechnologyStaffingTelecommunicationsTextilesTitled VehiclesTransportationTruckingVeterinary TechnologyVeterinarianWarehousing/StorageWaste or RecyclingWholesale

Yearly Gross Sales*
Select OneLess than $500,000$500,000 - $1 million$1 million - $2.5 million$2.5 million - $5 million$5 million - $10 million$10 million - $20 million$20 million - $50 million$50 million - $100 millionGreater than $100 million

Monthly Visa/Mastercard*
Select One$5,000 - $10,000$10,000 - $20,000$20,000 - $50,000$50,000 - $100,000$100,000 - $250,000$250,000 - $500,000$5000,000 - $1,000,000

Cash Usage
Select OneBusiness Working CapitalEquipment PurchaseAdvertising/MarketingRemodeling/UpgradesProduct DevelopmentTrainingTrade Show ParticipationExpansion/New LocationBuying Out a Business PartnerBusiness TaxesPayrollBuying InventoryTemporary StaffingOther

3. Contact Information

Phone*

Alternate Phone

Fax

Email*

How did you hear about us?
Select OneArticleEmailMagazine/Newspaper AdNewsletterRadioStatement MessagePhone CallPostcardLetterSales RepSearch EngineCredit Card ProcessorTVWord of MouthVendorOther WebsiteFacebookTwitterBlogTrade Show ConferenceOnline DirectoryOther

Additional Comments

Please note: This electronic application form conveys your interest in pursuing Merchant Cash Advances (also sometimes called Business Cash Advances) with Direct Merchant Advance. Once we receive your electronic application, a Sales Representative will contact you to complete the Merchant Cash Advance application process. By clicking the SUBMIT button, you confirm that you have reviewed and agreed to DMA's Terms of Use and Privacy Policy.