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Merchant Application

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Legal Business Name*

Name*

Doing Business As

Ownership Percentage

Federal Tax ID*

Home Address*

City*

State (2-letter)*

Zip*

Physical Address*

City*

State (2-letter)*

Zip*

Social Security Number*

Telephone*

Date of Birth*

Email*

Home Phone*

Cell Phone

Partner Name

Your Signature

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Date/Time

04/18/2026 6:03:25 PM

Your IP Address

2600:1f28:365:80b0:1a6b:8952:8e38:17b

Applicant authorizes Lily Advance LLC its assigns, agents, banks or financial institutions to obtain an investigative or consumer report from a credit bureau or a credit agency and to investigate the references given on any other statement or data obtained from applicant.