[Imported Form] Triple S Funding

Business Information
Legal/Corporate Name:*
DBA:
Business Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone:*

Area CodePhone Number
Email:*
Type of Business:*

RetailWholesaleMO/TORestaurantSupermarketOther
Does your business accept credit card payment?

YesNo
Business Start Date:*

MonthDayYear
Length of Ownership:
Federal Tax ID:*
Product/Services Sold:
Amount of Capital Needed:
Merchant/Owner Information
Corporate Officer/Owner’s Name:*
Title:
Ownership %:*
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone:

Area CodePhone Number
Cell Phone:

Area CodePhone Number
SSN:*
DOB:*

MonthDayYear
Partner Information
Partner Name:
Title:
Ownership %:
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone:

Area CodePhone Number
Cell Phone:

Area CodePhone Number
SSN:
DOB:

MonthDayYear
Upload the last 4 months Business Bank Statements:
Bank Statement 1

Cancelof
Bank Statement 2

Cancelof
Bank Statement 3

Cancelof
Bank Statement 4

Cancelof
Merchant/Owner Signature*

Clear
Partner Signature

Clear
By signing above, each of the above listed business and business owner/officer (individually and collectively, “you”) authorizes JAKOB 555 DBA Triple S Funding, its agents, representatives, successors, assigns, designees, banks, and financial institutions (“Recipients”) that may be involved with or acquire commercial loans having daily repayment features or purchases of future receivables including Merchant Cash Advance transactions to request and obtain from a consumer reporting agency, personal and business consumer credit reports and that may be involved with or acquire commercial loans having daily repayment features or purchases of future receivables including Merchant Cash Advance transactions. If this Application is approved, each of the undersigned also authorizes us to obtain subsequent consumer reports in connection with your merchant cash advance agreement with us including, without limitation, and modification or amendments thereto. Each of the undersigned furthermore agrees that all references, including banks and consumer reporting agencies, may release any and all personal and business credit financial information to us. It is our policy to obtain certain information in order to verify your identity while processing your application.
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