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Merchant Cash Advance Request This application form conveys your interest in pursuing a Merchant Cash Advance. A National Payment Systems® Sales Representative will contact you to complete this Merchant Cash Advance application process. Please Note: To be eligible for review, your business must process a minimum of $5,000 per month. There is no charge for this review & quote service. Please Complete the Form Accurately and Answer All Questions Presented! INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL Incomplete applications WILL NOT be processed and will delay the prompt servicing of your request! Business Name (d/b/a) Corporate Name Contact Person Street Address City State Zip Phone Fax Email Products Number of years in Business: New 1 Year 2 Years 3 Years 4+ Years Click if a Storefront: In Home: Monthly Bankcard Sales Transactions/month Yearly Gross Sales Monthly Visa/MC Sales Click for Additional Info: Seasonal? Previous Bankruptcy? Other Advances Outstanding? Need Equipment Financing Info?: Best time to Contact Date Funds Desired # of Locations COMMENTS/QUESTIONS Your feedback is important to the staff at NPS® Merchant Funding Thank you. Your privacy is also of uptmost importance to us. We do not provide any information collected from our site to any third party without your permission.