Capitex Application Form

Business Legal Name*

Doing Business As*

Legal Entity*

Federal Tax ID*

Business Phone*

Company Website

Cell Phone*

Business Fax

Email Address*

Business Start Date*

Date

State of Incorporation*

Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Full Legal Name Owner 1*

% of Ownership*

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address*

Cell Phone*

Date of Birth*

Date

Social Security Number*

Full Legal Name Owner 2

% of Ownership

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address

Cell Phone

Date of Birth

Date

Social Security Number

Business Description

Rent or Mortgage / Owned?*

RentMortgage / Owned

Monthly Rent / Mortgage Payment*

Landlord Name*

Landlord Contact Number

Please enter a valid phone number.

How much capital is being requested?*

When do you want to be funded?*

What is the capital being requested for?*

Credit Card Processing Monthly Volume*

Total Monthly Sales (All Forms Revenue)*

Current Credit Card Processor*

Do you currently have a merchant cash advance?*

YesNo

If yes, what is current outstanding balance?

Which representative has helped you today?*

By signing below, each of the businesses and their respective owner(s)/officer(s) listed above (individually and collectively referred to as "you") hereby authorizes Capitex Funding ("Capitex"), as well as its representatives, successors, assigns, and designees (collectively referred to as "Recipients"), to obtain consumer, personal, business, and investigative reports and other information about you. 'Recipients' as used here also includes third-party lenders or funders that provide loans or other forms of financing who provide financings having daily, weekly and monthly repayment features (collectively referred to as "Transactions"). This includes obtaining credit card processor statements and bank statements and credit reports from one or more consumer reporting agencies (e.g., Trans Union, Experian, and Equifax), other credit bureaus, banks, creditors, and third parties. You also authorize Capitex to transmit this application form, as well as any of the information obtained in connection with this application, to any or all of the Recipients for the purposes of attempting to facilitate a Transaction. Furthermore, you consent to the release of any information relating to any of you, to Capitex and each of the Recipients, for their own respective purposes.

Signature

Referral

Merchant Pre-Qualification

Owner / Principal Information

2nd Owner / Principal Information (optional)

Business Information

Funding Information