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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

09/04/2026 8:41:38 PM

Your IP Address

114.119.143.119

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.