WORKING CAPITAL PRE-QUALIFICATION FORM
CONTACT INFORMATION
Business Legal Name:
Business DBA (if applicable):
Business Phone:
Mobile Phone:
Business Fax:
Other Phone:
Website:
Email:
example@example.com
Address
Physical Address
Street Address Line 2
City
State / Province
Zip
Address
Mailing Address
Street Address Line 2
City
State / Province
Zip
BUSINESS INFORMATION
Legal Entity (select one)
Corporation
LLC
Partnership
LP
LLP
Sole Proprietorship
Business Start Date:
/
Month
/
Day
Year
Date
Federal Tax ID:
Home based business?
Yes
No
Open Judgements or liens?
Yes
No
Open Bankruptcies
Yes
No
State of Inc/LLC:
Business Description:
Industry Type (SIC Code):
Business rent/ Mortgage info
Rented/Leased
Mortgaged
Mthly Rent/Lease/Mtg Payment:
Remaining Term for Rent/Lease:
Payment Current?
Yes
No
Landlord/Mortgage Company Contact:
Phone Number:
FUNDING INFORMATION
Amount Requested:
When Are Funds Needed:
Desired Use of Funding Proceeds:
Gross Annual Sales:
Gross Monthly Sales:
Monthly Credit Card Volume:
Do you have any current cash advances?
Yes
No
Cash Advance/Loan Balance:
Current Credit Card Processing Company:
Account Number:
OWNER/PRINCIPAL INFORMTION
First Name:
MI:
Last Name:
Title:
ownership %
Home Address:
City
State
Zip Code
Mobile phone
Home Phone:
Date of Birth:
/
Month
/
Day
Year
Date
SS#:
CO-OWNER/PRINCIPAL INFORMATION
First Name:
MI:
Last Name:
Title:
ownership %
Home Address:
City
State
Zip Code
Mobile phone
Home Phone:
Date of Birth:
/
Month
/
Day
Year
Date
SS#:
AUTHORIZATION
Owner Signature:
Clear
Printed Name:
Date:
/
Month
/
Day
Year
Date
Co Owner Signature:
Clear
Printed Name:
Date:
/
Month
/
Day
Year
Date
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