Funding Application Form

Subtitle or short description

Legal Business Name

As seen on your tax returns

Company DBA

If Applicable

Company Tax ID

Date Business Established

Type of Business Entity

Business Identity Code Or Industry

This is found on your tax reutrn, or list your industry here:

State of Incorporation

Number of Locations

Number of Employees

Business Phone

Business Primary Address

First / Last name

Title

Job Title -Company Role

Email address

Personal Phone number

Date of Birth

YYYY

SSN#

Address

Own your home?

Select allClear choices

Yes

Monthly Rent/Mortgage Obligation

Gross Annual Revenues

Average Monthly Revenues

Business Location

Select allClear choices

Leased

Mortgaged

Work At Home

Monthly Rent/MTG for Business Location

USD

Do you have any merchant cash advances for your business? If So please label the Lender and Amount.

Please list any business debts

(credit cards, LOCs, factor lines, auto payments, equipment loans, leases, etc...)

Requested Funding Amount

USD

Business Funding Use Notes:

Please elaborate on how you plan to use the funds. This will help our system pair you with the best funding programs available.

First / Last name

Date

YYYY

Signature

The Merchant and Owner(s)/Officer(s) identified above (individually, an “Applicant”) each represents, acknowledges and agrees that (1) all information and

documents provided to Representative including credit card processor statements are true, accurate and complete, (2) Applicant will immediately notify

Representative of any change in such information or financial condition, (3) Applicant authorizes Representative to disclose all information and documents that

Representative may obtain including credit reports to other persons or entities (collectively, "Assignees") that may be involved with or acquire commercial loans

having daily repayment features or purchases of future receivables including Merchant Cash Advance transactions, including without limitation the application

therefor (collectively, "Transactions"), and each Assignee is authorized to use such information and documents, and share such information and documents with

other Assignees, in connection with potential Transactions, (4) Representative and each Assignee will rely upon the accuracy and completeness of such

information and documents, (5) Representative, Assignees, and each of their representatives, successors, assigns and designees (collectively, “Recipients”) are

authorized to request and receive any investigative reports, credit reports, statements from creditors or financial institutions, verification of information, or any

other information that a Recipient deems necessary, (6) Applicant waives and releases any claims against Recipients and any information‐providers arising from

any act or omission relating to the requesting, receiving or release of information, and (7) each Owner/Officer represents that he or she is authorized to sign this

form on behalf of Merchant. A copy of this authorization may be accepted as an original. A copy of this authorization may be accepted as an original. The term

“Representative” shall mean any funding source looking to offer, make available, or provide to the Merchant access to loans or merchant cash advances based

on such Merchant’s future receivables or sales and/or structured with a periodic repayment feature.

Verification

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