Application Form - Magic Ink SMP

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Person Receiving Services

Is Applicant The Person Receiving Services*

Yes

Name (Person Receiving Services)*

Email (Person Receiving Services)*

Phone (Person Receiving Services)*

Loan Information

Amount Requested (in $)*

Please enter a number from 0 to 100000.

Please round your amount requested

Purchase Type*

Date of Purchase*

Date must be within 60 days. If not yet set, please provide an estimate.

Merchant

Merchant*

Applicant

First Name*

Last Name*

Date of Birth*

Social Security Number*

Confirm Social Security Number*

Email Address*

Please enter your correct personal email address to avoid processing delays

Cell Phone Number*

Home Phone Number

Home

Home Address (no P.O. Boxes)*

Street Address Address Line 2 City State ZIP Code

*U.S. Addresses Only*

Monthly Mortgage/Rent Payment ($)*

Please enter a number from 0 to 20000.

Source of Personal Income

Employment Status*

Total Monthly Income Before tax ($)*

Input the GROSS income you personally receive MONTHLY from your employment. Income may be subject to verification.

Other Personal Verifiable Monthly Income ($)

Income from alimony, child support or separate maintenance payments need not be disclosed if you do not wish to have this income considered as a basis for repaying this obligation.

Please check this box if any of your income is non-taxable (e.g. Retirement, Child Support, Alimony)

Tax returns required. Total Gross Monthly income should be based off Adjusted Gross Income on returns.

Total Annual Income ($)

Please check Total Annual Income is correct

Employer Name

Employer Phone Number*

Occupation*

Start Date at Current Job