Finance Application
Vendor
Lead Owner
Business Information
Legal Business Name
*
Entity Type
*
Please Select
LLC
Sole Proprietorship
C Corporation
S Corporation
LLP/Partnership
Business Start Date
/
Month
/
Day
Year
Tax ID (EIN)
Sole Props - enter your SSN if not available
Business Phone
*
Gross Annual Revenue
*
Business Description / Industry
Business Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
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California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
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Louisiana
Maine
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Owner Information
Full Name
*
First Name
Last Name
Phone Number
*
Email
*
Ownership %
*
Professional License Type
*
(Examples: MD, ARPN, NP, etc)
Estimated Credit Score
*
Date of Birth
*
/
Month
/
Day
Year
Social Security Number
*
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
Finance Request Information
Amount Requesting
*
I certify that my answers are true and complete to the best of my knowledge. By signing below, each of the above listed Business Owner(s)/Officer(s)/Principal(s) and Business (individually and collectively, "You") certify that all information and documents submitted in connection with this Funding Application ("Application") are accurate, true, correct and complete; and that You will immediately notify JR Capital, LLC ("JR") or any of its representatives, successors, assigns, designees, agents, partners or affiliates ("Recipients") of any change in such information or financial condition. You acknowledge that any false statements may be considered fraud. You acknowledge that the Recipients are relying on the information You provide. You further authorize JR and each of the Recipients that may be involved with or acquire commercial loans having daily repayment features or purchases of future receivables including Merchant Cash Advance transactions (collectively, "Transactions" ) to obtain consumer or personal, business and investigative reports and other information about You, including, but not limited to 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, financial institutions, creditors and other third parties. You authorize Recipients to receive relevant information regarding the commercial lease for the above-referenced premises from our leasing company and/or agent. You also authorize JR to transmit this Application, along with any of the foregoing information obtained in connection with this Application, to any or all of the Recipients for the foregoing purposes. A photocopy of the Application will be deemed acceptable for release of credit and/or investigatory information.
*
Applicant Signature
Date Signed
*
/
Month
/
Day
Year
Submit
Submit
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