Gold Medal Funding

Gold Medal Funding

Administrative Form
What kind of program are you looking for?*
Agent/Referring Party:
Amount requested:
Business Information
Business Legal Name *
DBA:
Tax ID/EIN*
Industry Type*
Entity Type*
Number of Employees*
Business Adress*

Street Address

Street Address Line 2

CityState

Zip Code
Is your business home based?*

YesNo
Do you have a different billing address?

YesNo
Billing Adress (If different from business address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone #*
Please enter a valid phone number.Format: (000) 000-0000.
Business Email
example@example.com
Business Start Date*

MonthDayYear
Annual Revenue: *
Do you have a Merchant Cash Advance or ACH Funding?*

YesNo
Name of Lender
Approximate Balance
Current Credit Card Processor:
Owners Information
Owner 1
First Name*
Last Name*
Date of Birth*

MonthDayYear
Date
SSN*
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Personal Email*
example@example.com
Driver's license
Credit score:*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you own the property you're currently living in?*

YesNo
Years living there:
Is there a second Owner?

YesNo
Owner 2
First Name
Last Name
Date of Birth

MonthDayYear
Date
SSN
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Personal Email
example@example.com
Driver's license
Credit score:
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you own the property?

YesNo
Years living there:
Business Location
Rent or Own
Term on lease
Monthly Rent
Landlord or Mortgage Co
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Annual Salary/Compensation:
Real Estate Owned Value:
Retirement Account Balance:
Cash/Savings/Stock Balance
Credit Card Balance:
Mortgage(s) Balance
Auto Loan(s) Balance
Total Net Worth
Most recent month to date (If submiting application after 10th of current month)

Cancelof
Attatch 4 months business bank statements

Cancelof
3 Years business and personal tax returns (if required)

Cancelof
Active Business License

Cancelof
Drives license

Cancelof
Voided Check

Cancelof
By signing below, each of the above-listed Business Applicant and Principal Owner (individually and collectively, “you”) authorizes Gold Medal Funding LLC (“Gold Medal Funding LLC”) and each of its representatives, successors, assigns, and designees that may be involved with or acquire purchases of future receivables, including Merchant Cash Advance transactions (“Recipients”), to obtain consumer, personal, and business 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 (1) to review the transaction you have applied for, including to authenticate your identity, verify information in your application, make underwriting decisions, and for related purposes, and (2) if your application results in your entering into any transaction with any of the Recipients, to service, monitor, collect, and enforce the transaction. You also authorize Gold Medal Funding LLC, as agent for the Recipients, 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 the release, by any creditor or financial institution, of any information relating to any of you, to Gold Medal Funding LLC, as agent on behalf of the Recipients, and to each of the Recipients, on its own behalf.*

I agree
Owner 1*
Owner 2
Date*

MonthDayYear
Date
Date

MonthDayYear
Date
Should be Empty:

Gold Medal Funding

Business Information

Owners Information

Owner 1

Owner 2

Business Location