Free Life Funding | Merchant Onboard

Individual Completing Application

First Name

Last Name

Cell Phone

Please provide your valid medical license/certification information:

I am not required to maintain a state or local license.

Name of Licensed Medical Professional(s)

License/Certification Number

Name of Medical/Certification Board

Expiration Date (If Applicable)

Please provide your state or local contractor’s license number (if applicable):

I am not required to maintain a state or local contractor’s license for my trade.

State or Local License Number

Expiration Date (If Applicable)

Billing Address (No PO Boxes)

Address 1

Address 2

City

Zip

Mailing Address Same as Billing address

Address 1

Address 2

City

Zip

Principal/Owner Information

I am an owner/principal

First Name

Last Name

Email Address

Phone Number

Ownership Start Date

Social Security Number

Ownership %

Date of Birth (mm/dd/yyyy)

Residential Address

Address 1

Address 2

City

Zip

Please upload additional documents (skipping this step will delay approval)

Voided Check

A voided check is required to set up direct payments to your bank account.

Browse

File must be less than 3 MB.
Allowed file types: gif png jpeg pdf.

Customer Sales Agreement

A copy of your sales agreement expedites the servicing of consumer applications.

Browse

File must be less than 3 MB.
Allowed file types: gif png jpeg pdf.

By checking the box below you verify that you have read and agree to the Merchant Agreement and Disclosures.

I authorize Platform Administrator to verify or obtain further information as it may deem necessary concerning the entity and its Partners and Owners, including the use of credit reporting agencies.

I certify that all the information is true and accurate to the best of my knowledge.
By submitting this application, I certify that I have read and agree to the Merchant Agreement and Disclosures.

By checking the box below you verify that you have read and agree to the Merchant Agreement and Disclosures.

I authorize Platform Administrator to verify or obtain further information as it may deem necessary concerning the entity and its Partners and Owners, including the use of credit reporting agencies.

I certify that all the information is true and accurate to the best of my knowledge.
By submitting this application, I certify that I have read and agree to the Merchant Agreement and Disclosures.

Start Growing Your Business Today

Provide a few quick details below to get started!

Individual Completing Application

Company Information

Please provide your valid medical license/certification information:

Please provide your state or local contractor’s license number (if applicable):

Billing Address (No PO Boxes)

Mailing Address Same as Billing address

Principal/Owner Information

Residential Address

Please upload additional documents (skipping this step will delay approval)

Voided Check

A voided check is required to set up direct payments to your bank account.

File must be less than 3 MB.
Allowed file types: gif png jpeg pdf.

Customer Sales Agreement

A copy of your sales agreement expedites the servicing of consumer applications.

File must be less than 3 MB.
Allowed file types: gif png jpeg pdf.

Please upload additional documents (skipping this step will delay approval)

Voided Check

A voided check is required to set up direct payments to your bank account.

File must be less than 3 MB.Allowed file types: gif png jpeg pdf.

Customer Sales Agreement

A copy of your sales agreement expedites the servicing of consumer applications.

File must be less than 3 MB.Allowed file types: gif png jpeg pdf.

File must be less than 3 MB.
Allowed file types: gif png jpeg pdf.

File must be less than 3 MB.
Allowed file types: gif png jpeg pdf.