Application Form

Apply for Funding

Business Legal Name (Required)

Business DBA Name

Address (Required)

City

State

ZIP Code

Phone

Mobile

Product / Service Sold

Partnership (Required)

Corp

Sole Prop

LLC

Other (Required)

Store Front

Office

Home

Date Business Started (Required)

EIN (Required)

OWNER/PRINCIPLE INFORMATION

OWNER #1

Name (Required)

Address (Required)

City (Required)

State (Required)

Zip (Required)

Phone

example@example.com

% of Ownership (Required)

Date of Birth (Required)

SSN# (Required)

Credit Score

OWNER #2 (IF APPLICABLE)

Name

Address

City

State

Zip

Phone

example@example.com

% of Ownership

Date of Birth

SSN#

Credit Score

FINANCIAL INFORMATION

Amount of Funding Requesting

Purpose of Funds

Existing Advances:

Yes

If yes, what is the remaining balance of the first position

Current Advance with

Payment

If yes, what is the remaining balance of the second position

Current Advance with

Payment

LANDLORD OR MORTGAGE INFORMATION

Rent / Mortgage Monthly Amount

Landlord / Mortgage Contact

Landlord / Mortgage Number

Owner #1

By signing below, the Merchant and its owners/principals: (1) certify that all information and documents submitted in connection with this Application are true, correct, and complete; and (2) authorize the recipient and its affiliates to receive credit reports, including credit card processor statements and bank statements, from one or more consumer reporting agencies, such as TransUnion, Experian, and Equifax, and from other credit bureaus, banks, creditors, and other third parties regarding the Merchant and its owners and principals, to verify any information provided on the Application.

Owner/Principal Signature

Print Name

Date

Owner #2

Owner/Principle Signature

Print Name

Date

Upload Bank Statements and Month to Date (MTD)

Upload files

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Max. file size: 3 GB