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Use of Funds
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Purchase Equipment
Hire Additional Employee
Expand or Renovate
Cover Payroll
Pay Taxes
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Business Address
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Armed Forces Americas
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Zip
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Business Phone
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Tax ID
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Annual Revenue
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Type Of Entity
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Construction/Utilities/Contracting
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Outstanding Business Loan Balance
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Monthly Credit Card Sales
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Business Start Date
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Fax
Email
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Owner/Officer Information - Owner #1
Owner Name
*
Percentage of Ownership
*
Current Address
*
City
*
State
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Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip
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Email
Phone
Date of Birth
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MM slash DD slash YYYY
Social Security Number
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Owner/Officer Information - Owner #2
Owner Name
Percentage of Ownership
Current Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip
Email
Phone
Date of Birth
MM slash DD slash YYYY
Social Security Number
Business Property
Rent/Own
Rent
Own
Monthly Payment
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Landlord
Landlord Phone
Additional Comments
Please include any additional info below
Last 4 Months of Business Bank Statements
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Max. file size: 512 MB, Max. files: 10.
E-signature
Owner # 1
Owner # 2
Authorization
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I agree to the privacy policy.
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. 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.
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