Business Information
Legal/Corporate Name:
*
DBA:
Business Address:
*
Street Address
Street Address Line 2
City
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone:
*
-
Area Code
Phone Number
Email:
*
Type of Business:
*
Retail
Wholesale
MO/TO
Restaurant
Supermarket
Other
Does your business accept credit card payment?
Yes
No
Business Start Date:
*
-
Month
-
Day
Year
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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
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone:
-
Area Code
Phone Number
Cell Phone:
-
Area Code
Phone Number
SSN:
*
DOB:
*
-
Month
-
Day
Year
Date Picker Icon
Partner Information
Partner Name:
Title:
Ownership %:
Home Address:
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone:
-
Area Code
Phone Number
Cell Phone:
-
Area Code
Phone Number
SSN:
DOB:
-
Month
-
Day
Year
Date Picker Icon
Upload the last 4 months Business Bank Statements:
Bank Statement 1
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Bank Statement 2
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Bank Statement 3
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Bank Statement 4
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Merchant/Owner Signature
*
Partner Signature
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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