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Client Financing
Financing Solutions For Your Products & Services
Client Financing
Financing Solutions For Your Products & Services
Selling on Amz LLC
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Selling on Amz LLC
Selling on Amz LLC
Step
1
of
4
25%
Personal Information
First Name
(Required)
Middle Name
Last Name
(Required)
Address
(Required)
City
(Required)
State
(Required)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
(Required)
Own Or Rent
(Required)
OWN
RENT
OTHER
Time At Address
(Required)
o
1
2
3
4
5
6
7
8
9
10+
Monthly Payment
(Required)
DOB
(Required)
SSN
(Required)
Phone Number
(Required)
Email Address
(Required)
Income/Employment Information
Employer Name
(Required)
If you are self employed, list “self employed” as the Employer.
Occupation / Title
(Required)
What is your job title or the industry you work in?
Phone Number
(Required)
Length of Employment
(Required)
0
1
2
3
4
5
6
7
8
9
10+
Average Income
(Required)
Income Period
(Required)
WEEK
MONTH
YEAR
How often are you paid?
Payment Information (ACH)
We collect two (2) forms of payment; Credit/Debit Card & ACH.
Bank Name
(Required)
Account Number
(Required)
Routing Number
(Required)
Account Type
(Required)
Checking
Savings
Payment Information (Card)
We collect two (2) forms of payment; Credit/Debit Card & ACH.
Card Number
(Required)
Card Brand
(Required)
Visa
Mastercard
Discover
Amex
Expiration Month
(Required)
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Year
(Required)
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
CVV
(Required)
Two References
Please provide two references. They will be no outreach to the references provided unless the customer defaults on payments and avoids all collection efforts.
Reference #1
First Name
(Required)
Last Name
(Required)
Phone Number
(Required)
Relationship
(Required)
Parent
Grandparent
Sibling
Spouse
Significant Other
Friend
Co-Worker
Child
In-Law
Cousin
Aunt
Uncle
Other
Reference #2
First Name
(Required)
Last Name
(Required)
Phone Number
(Required)
Relationship
(Required)
Parent
Grandparent
Sibling
Spouse
Significant Other
Friend
Co-Worker
Child
In-Law
Cousin
Aunt
Uncle
Other