Coined Inc. Customer Application

Customer Application

Coined Inc.
Business Legal Name:*
DBA (Doing Business As):*
Legal Entity:*

LLCSole PropCorp
State of Incorporation:*
EIN Number (Tax ID):*
Industry Type:*
Business Phone Number:*
Business Email:*
example@example.com
Full Business Address:*
Is it Rented or Owned:*

RentedOwned
Rent / Mortgage Payment:*
Start Date:*

MonthDayYear
Date
Gross Annual Sales (Previous Tax Return):*
Owner Information
Full Name:*
Phone Number*
Please enter a valid phone number.
Date Of Birth*

MonthDayYear
Date
Home Address*
Email*
example@example.com
Ownership Percentage*
Social Security Number*
Second Owner Information (If Applicable)
Full Name
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Home Address
Email
example@example.com
Ownership Percentage
Social Security Number

Funding Amount
How much is needed?*
What will the funds be used for?*
Do you have any current cash advances?*

YesNo
How many cash advances? (If Applicable)
Documents

Here you can upload your most 4 recent business banking statements (Required to Determine Loan Amount)
Please upload your 4 most recent business bank statements

Cancelof
Disclosure and Signature
By signing below, each of the above Businesses and Business Owners/Officers (Individually and collectively, “you”) authorize Coined Inc. 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 MCA 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 Coined Inc. 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 release, by any creditor or financial institution, of any information relating to you, to Coined Inc. and to each of the recipients, on its own behalf
Acknowledgement*

I have read and agree to the terms above
Print Full Name*
Signature*

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Signed Date

MonthDayYear
Date
Should be Empty:

Customer Application

Owner Information

Second Owner Information (If Applicable)

Funding Amount

Documents

Disclosure and Signature