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    Donald E. Mitchell Agency, Inc.

    860 N. DeWitt Place. # 1501 ♦ Chicago, IL. 60611 ♦ (312) 577-9402 ♦ (248) 210-9149

    Merchant Information (Please complete All Information below Accurately)
    Legal Name:
    D/B/A Name:
    Merchant Corporate/Legal Address:
    City:
    State:
    Zip:
    UMCA ID:
    Type of Business:
    Phone:
    Fax:
    WebSite Address:
    Legal Form of Entity & Authorized Signer (Please Check Box and Complete as Indicated)
    Corporation
    Name of President:
    Name of Officer Signing Applications:
    Title:
    LLC
    Name of Manager/Managing Member:
    (Must Be Signer of Application)
    Partnership
    Name of General Partner:
    (Must Be Signer of Application)
    Sole Proprietorshop
    Name of Owner:
    (Must Be Signer of Application)
    Date of Organization:
    State of Organization:
    Federal Tax ID #:
    Number of Partners/Shareholders/Members/Owners in Business: (Please List Them)
    1
    3
    2
    4
    Merchant Primary Establishment Address (if Different)
    City:
    State:
    Zip:
    Phone:
    Fax:
    Cell Phone:
    How Long Have You Owned the Establishment?
    Years:
    Month:
    Number of Employees:
    Number of Additional Locations Under Same Legal Corporate Entity:
    Have the Business or Owners Ever Field For Bankruptcy?
    YesNo

    When?
    Name of Landlord
    Name of Landlord
    Merchant Sales Information
    What are Your Total Annual Credit Card Sales?
    What are Your Total Annual Sales (Cash +CC) ?
    Number Of Seats (if applicable)
    Cuisine Type (if applicable)
    Is Your Business Seasonal?
    YesNo

    Percentage Sales Decrease In Low Volume Months
    %
    List Low volume Months:
    Cash Needs (Minimum of $5,000,up to a Maximum of $500,0000 Based Upon Approved Credit)
    Total Cash Needed:
    Date When Cash Is Needed:
    What is Your Desired Weekly Payment Amount?
    Cash Will Be Used For (Please Check One or More)
    Expansion
    Renovations
    Equipment
    Inventory
    Open Another Location
    Cash Flow
    Pay Taxes
    Marketing
    Pay Off existing Advance
    Other:
    Existing Cash / Financing Providers
    Name of Cash Provider:
    Current Balance:
    Amount Funded:
    Rate:
    %
    Do You Want To Pay Them Off?
    YesNo

    Date Funded:
    Please attach the more current statement on your account if you want to pay off this cash provider
    Continue
    Merchant Name:
    Name of 2nd. Cash Prov.:
    Current Balance:
    Amount Funded:
    Rate:
    %
    Do You Want To Pay Them Off?
    YesNo

    Information on Business Owner/Primary Guarantor (required)
    Name of Guarantor:
    Date of Birth:
    Social Security Number:
    Drivers License #:
    State:
    E-Maiil Address:
    Home Address:
    City:
    State:
    Zip:
    Home Phone:
    Cell Phone:
    Spouses Name:
    Do You Own or Rent ?
    Own
    Rent
    How Long ?
    Years:
    Month:
    Have You Declared Personal Bankruptcy in the Past ?
    YesNo

    When ?:
    Do You Currently Have Collection Issues Pending ?
    YesNo

    I hereby give permission to Advance Restaurant Finance, LLC ("ARF"), or any agent or credit-reporting agency that it may designate, to obtain any and all information concerning my assets and other credit matters, which they may require in connection with this credit Application. I specifically acknowledge and agree that (1) all statements which I have made in this Application are made for purposes of obtaining the financing, (2) verification and reverification of any information which I have supplied in connection with this Application may be made at any time by ARF, either directly or through a credit reporting agency, from any source named in this Application and the original copy of the Application will be retained by ARF, even if the financing is not approved, (3) ARF will rely on the information which I have supplied herein and I have the continuing obligation to amed and/or supplement that information if any of the material facts which I have represented should change prior to the total obligations under the credit Aggrement being paid in full and (4) each Guarantor, upon request from time to time by ARF, will provide ARF withfinancial statments and such other information as ARF deems appropriate, all in form and detail satisfactory to ARF. This Application is part of a credit review process and additional information may be required. I hereby authorize ARF to submit this Application to one or more bands. Any institution considering this Application will make its own credit decision regarding this Applicaton. The sales representative submitting this Application cannot extend credit or commit to any financing or funding until a credit decision has been made by the appropriate institution.
    Signature of Merchant Authorized Signer & Loan Guarantor:
    X
    Date:
    Merchant Authorized Signer's Title:
    X
    1. This application must be completed in its entirety. It must be signed and dated by an Authorized Signer of the Merchant who is also the Load Guarantor.
    2. Along with this application please fax the Merchant's three most current credit card statements and the most current bank statment. However, if cash sales are materially higher than credit card sales (by at least 25%) then please fax three months of the most current bank statements and the most current credit card statement.
    3. How would you like to be contacted about this financing request?
    Business Phone
    Cell Phone
    Home Phone
    E-Mail
    Business Fax
    Transmittal of this Application and all information to be attached may be made by facsimile transmission.
    PLEASE FAX THIS APPLICATION TO
    Source of Application (For Office Use Only)
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    Donald E. Mitchell Agency, Inc.

    860 N. DeWitt Place. # 1501 ♦ Chicago, IL. 60611 ♦ (312) 577-9402 ♦ (248) 210-9149

    Merchant Information (Please complete All Information below Accurately)
    Legal Name:
    D/B/A Name:
    Merchant Corporate/Legal Address:
    City:
    State:
    Zip:
    Phone:
    Fax:
    WebSite Address:
    Information on Co-Guarantor (Required)
    Name of Guarantor:
    Date of Birth:
    Social Security Number:
    Drivers License #:
    State:
    E-Maiil Address:
    Home Address:
    City:
    State:
    Zip:
    Home Phone:
    Cell Phone:
    Spouses Name:
    Do You Own or Rent ?
    Own
    Rent
    How Long ?
    Years
    Month
    Have You Declared Personal Bankruptcy in the Past ?
    YesNo

    When ?
    Do You Currently Have Collection Issues Pending ?
    YesNo

    I/We hereby give permission to Advance Restaurant Finance, LLC ("ARF"), or any agent or credit-reporting agency that it may designate, to obtain any and all information concerning my/our assets and other credit matters, which they may require in connection with this credit Application. I/We specifically acknowledge(s) and agree(s) that (1) all statements which I/we have made in this Application are made for purposes of obtaining the financing, (2) verification and reverification of any information which I/we have supplied in connection with this Application may be made at any time by ARF, either directly or through a credit reporting agency, from any source named in this Application and the original copy of the Application will be retained by ARF, even if the financing is not approved, (3) ARF will rely on the information which I/we have supplied herein and I/we have the continuing obligation to amed and/or supplement that information if any of the material facts which I/we have represented should change prior to the total obligations under the credit Aggrement being paid in full and (4) each Guarantor, upon request from time to time by ARF, will provide ARF withfinancial statments and such other information as ARF deems appropriate, all in form and detail satisfactory to ARF. This Application is part of a credit review process and additional information may be required. I/we hereby authorize ARF to submit this Application to one or more bands. Any institution considering this Application will make its own credit decision regarding this Applicaton. The sales representative submitting this Application cannot extend credit or commit to any financing or funding until a credit decision has been made by the appropriate institution.
    Signaure of Merchant Authorized Signer: x
    Date:
    Signature of Co-Guarantor: x
    Date:
    1. This application must be completed in its entirety. It must be signed and dated by an Authorized Signer of the Merchant and the Load Co-Guarantor.
    2. How would you (Co-Guarantor) like to be contacted about this financing request?
    Business Phone
    Cell Phone
    Home Phone
    E-Mail
    Business Fax
    Transmittal of this Application and all information to be attached may be made by facsimile transmission.
    PLEASE FAX THIS APPLICATION TO
    Source of Application (For Office Use Only)
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