DIGI Discoveries Business Intake Form

Is your company owned by one of the following individuals: minority, woman, individual with a disability, individual who is socially/economically challenged? If so, please indicate which apply.*

Business #1 Legal Company Name or any alternate or previous names the organization has used: *

Business #1 Tax ID No:

Is your company current on all county, city, local, state and federal taxes? If not, which one and do you have an arrangement set to pay these taxes?

Business #1 Industry

Number of W2 employees

Number of 1099 employees

Date of Business Incorporation

Date

Business #1 Website

Business #1 Email

example@example.com

Business #1 Phone Number

Format: (000) 000-0000.

Business #1 Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business #1 Mailing Address if Different

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

OwnRentVirtual

Business #2 Legal Company Name or any alternate or previous names the organization has used.

Business #2 Tax ID No:

Is your company current on all county, city, local, state and federal taxes? If not, which one and do you have an arrangement set to pay these taxes?

Business #2 Industry

Date of Business Incorporation

Date

Business #2 Website

Business #2 Email

example@example.com

Business #2 Phone Number

Format: (000) 000-0000.

Business #2 Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business #2 Mailing Address if Different

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

OwnRentVirtual

Monthly Rent/Mortgage: $ (If requesting financing)*

Landlord/Bank Name: (If requesting financing)*

Landlord Phone #: (If requesting financing)*

Not-for-profit Designation

Entity Name and Any alternate or previous names the organization has used:

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

TAX ID: If already applied for*

Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address if different*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Type of organization (corporation, trust, unincorporated association, etc.):

Date of formation or incorporation: If already applied for*

Date

State or country of incorporation or formation:

Purpose and Activities: Description of the organization's mission, purpose, and activities. Details about the organization's programs and services.*Please answer to the best of your ability.*

Title:

officers, directors, and key personnel

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Title:

officers, directors, and key personnel

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Title:

officers, directors, and key personnel

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Title:

officers, directors, and key personnel

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is there family or business relationships among any of these officers, directors, or key personnel? If so, explain.

Upload Statement 1

Upload Statement 2

Upload Statement 3

Upload Statement 4

Upload Statement 5

Upload Statement 6

Upload Business Documents

Upload Additional Documents

Average Monthly Revenue: $

Financing Amount Seeking $

Grants Amount Seeking $

YesNo

If yes, list the balances: $

The Merchant and Owner(s)/Officer(s) identified above (individually, an “Applicant”) each represents, acknowledges and agrees that (1) all information and documents provided to DiGi Discoveries LLC (“Company”) including credit card processor statements are true, accurate and complete, (2) Applicant will immediately notify Company of any change in such information or financial condition, (3) Applicant authorizes Company to disclose all information and documents that Company may obtain including credit reports to other persons or entities (collectively, “Assignees”) that may be involved with or acquire commercial loans or purchases of future receivables including Merchant Cash Advance transactions, including without limitation the application therefore (collectively, “Transactions”) and each assignee is authorized to use such information and documents and share such information and documents with other Assignees, in connection with potential Transactions, (4) Each Assignee will rely upon the accuracy and completeness of such information and documents (5) Company, Assignees, and each of their representatives, successors, assigns and designees (collectively, “Recipients”) are authorized to request and receive any investigative reports, credit reports, statements from creditors or financial institutions, verification of information, or any other information that a recipient deems necessary, (6) Applicant waives and releases any claims against Recipients and any information providers arising from any act or omission relating to the requesting, receiving or release of information, and (7) Each Owner/Officer represents that he or she is authorized to sign this form on behalf of Merchant.

YesNo

Signature*

Business Intake Form

Small Business Services Interest

Personal Information

Business Intake Form

Non-Profit Business Formation/IRS Form 1023 Entity Information:

Non-Profit Governance and Leadership:*

Upload Business Documents if requested*

Business Intake

DIGI Discoveries LLC Business Development and Consulting Services