Email Submission Form

Business Legal Name*

Business DBA Name*

Entity (Check One)*

Business Federal Tax ID*

State of Incorporation or Formation*

Industry Type (Sic Code or Description)*

Business Start Date*

Date

Address*

Physical Street Address

Street Address Line 2

CityState

Zip Code

Physical Location Phone #

Preferred Contact #

Business Website

Any Open Bankruptcies?

YesNo

Any Judgments / Liens?*

YesNo

Is your business Seasonal?

YesNo

Does the Merchant currently have any loans or advances for working capital? (Check one)

YesNo

If Yes, what is your current balance

Funding Company

Use of Proceeds*

Landlord Name

If yes, what are the peak months?

Location

RentedMortgaged

Monthly Payment

Name*

First NameLast Name

Job Title*

Ownership %*

SS#*

Date of Birth*

Date

Email*

example@example.com

Annual Income

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone number*

Cell

Name

First NameLast Name

Job Title

Ownership %

SS#

Date of Birth

Date

Email

example@example.com

Annual Income

Address

Street Address

Street Address Line 2

CityState

Zip Code

Home Phone

Cell Phone

By signing below, each of the above listed business and business owner/officer (individually and collectively, “you”) authorize Berkman Funding LLC (“BF”) and each of its representatives, successors, assigns and designees (“Recipients”) that may be involved with or acquire commercial loans having daily repayment features or purchases of future receivables including Merchant Cash Advance transactions, including without limitation the application therefor (collectively, “Transactions”) to obtain consumer or personal, business and investigative reports and other information about you, 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. You also authorize BF to transmit this application form, along with any of the foregoing information obtained in connection with this application, to any or all of the Recipients for the foregoing purposes. You also consent to the release, by any creditor or financial institution, of any information relating to any of you, to BF and to each of the Recipients, on its own behalf. This application is not valid unless submitted under an existing ISO agreement with BF.

Date*

Date

Bank Statement upload

Type a question*

Merchant Pre-Qualification Form

Type of Business

MCA History

Location Information

Owner / Officer Information (1)

Owner / Officer Information (2)

Authorizations