Application – Lenders Access | Business Funding Intelligence

Section 1

Business Information

Business Legal Name*

Business DBA

State of Incorporation*

Tax ID Number (EIN)*

Business Start Date

Industry Type

Business Entity Type*

Location Phone*

Preferred Contact Phone

Web Address

Business Email*

Physical Address

Street Address*

City*

State / Zip*

Billing Address (if different)

Street Address

City

State / Zip

Property

Property Status

Rented Mortgaged

Monthly Payment

Landlord Name

Landlord Phone

Section 2

Financial Information

Gross Annual Sales*

Avg Monthly CC Volume

Credit Card Processor

Open MCA or Loan Accounts

Do you have any open MCA or Loan Accounts?

Yes No

Lender 1

Balance 1

Lender 2

Balance 2

Credit History

Open judgments or tax liens?

Yes No

Balance

Open/discharged bankruptcies?

Yes No

Year

Section 3

Owner / Officer Information

Primary Owner / Officer

Title*

% of Ownership*

First Name*

Last Name*

SS#*

Date of Birth*

Home Phone

Mobile Phone*

Email Address*

Home Address*

City*

State / Zip*

Secondary Owner / Officer (if applicable)

Title

% of Ownership

First Name

Last Name

SS#

Date of Birth

Home Phone

Mobile Phone

Email Address

Home Address

City

State / Zip

Section 4

Funding Request

Use of Funds*

Desired Loan Amount*

Section 5

Authorization & Signatures

Primary Owner / Officer

Print Name*

Signature (type full name)*

Date*

Secondary Owner / Officer

Print Name

Signature (type full name)

Date

I have read and agree to the authorization above, and confirm the information provided in this application is true and accurate to the best of my knowledge.*

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Apply for Business Funding

Business Information

Financial Information

Owner / Officer Information

Primary Owner / Officer

Secondary Owner / Officer (if applicable)

Funding Request

Authorization & Signatures