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*First Name:
*Last Name:
*Company Name:
*Phone:
*Email:
Address:
City:
State:
Zip:
How long have you been in business?
Do you accept credit cards as a form of payment?	Yes No
If yes, what is your average monthly processing volume
Do you have at least one year remaining on your business lease?	Yes No
Are you currently involved in bankruptcy proceedings?	Yes No
How much in Visa and MasterCard sales do you process on average per month?
Have you ever received a merchant cash advance? If so, from what Company?
How did you hear about us? If by referral, please enter name of person who referred you.
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NOTE: This is a business cash advance and not a loan product.

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Testimonial

"I strongly recommend Express Working Capital. They were professional, courteous, and delivered on every promise they made. Plus, we will save over $10,000 in processing fees our first year."
Mark D., General Manager

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