NORTH SHORE CAPITAL GROUP FUNDING APPLICATION

I hereby confirm the Following:

I have a business checking account with 3 months' statementsI have a valid drivers license

BUSINESS INFORMATION*

LEGAL BUSINESS NAMEDBA NAME

INDUSTRY TYPE

BUSINESS ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

BUSINESS NUMBER*

Area CodePhone Number

This is a fill in the FEDERAL TAX ID *

BUSINESS START DATE   Date
BUSINESS TYPE:   RENT   OWN

AMOUNT REQUESTING:
USE OF FUNDS:   Type a label

TYPE OF ENTITY:

LLCSOLE PROPRIETORSHIPCORPORATIONNON PROFIT

PRINCIPAL OWNER NAME*

First NameLast Name

OWNERSHIP: blank
If not Sole owner, First and last name of secondary owner Type a label   and %
SSN:   Type a label
DOB:   Date
CELL   Area Code   Phone Number

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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 North Shore Capital Group including credit card processor statements are true, accurate and complete, (2) Applicant will immediately notify Versa Business Systems of any change in such information or financial condition, (3) Applicant authorizes North Shore Capital Group to disclose all information and documents that North Shore Capital Group may obtain including credit reports to other persons or entities (collectively, "Assignees") 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"), 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) North Shore Capital Group and each Assignee will rely upon the accuracy and completeness of such information and documents, (5) North Shore Capital Group, 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. A copy of this authorization may be accepted as an original. A copy of this authorization may be accepted as an original. The term “North Shore Capital Group” shall mean any funding source looking to offer, make available, or provide to the Merchant access to loans or merchant cash advances based on such Merchant’s future receivables or sales and/or structured with a periodic repayment feature.

Signature

Date

Last three months Business banking

Date

FUNDING APPLICATION

OWNERSHIP INFORMATION