Application Form

QuiKap Funding Inc.
925 Blvd. De Maisonneuve Ouest, Suite 260
Montreal, Quebec, Canada, H3A 0A5
support@quikapfunding.com | (438) 402-7925

Business Funding Application

Please complete the following information (3 to 5 minutes). An analyst will determine your eligibility and a funding specialist will contact you to review your options.

NOTE: Fields marked with an atsterix ( * ) are required.

Business Information:

Referral code - Optional

Business legal name*

Business operating name*

Business legal entity type*

Business phone number*

Business street address (not a PO Box)*

City / Town*

State / Province*

Zip / Postal code*

Country*

Time in business*

Industry / Profession*

Sub-sector / Specialty*

Employer / Business identification number - 9 digit (EIN / BIN)

Business website URL

Business Financials:

Total gross sales last year?*

Average monthly deposits in last 6 months*

Did any of those months go below $10,000?*

Number of monthly deposits*

Business property*

Monthly rent / mortgage payment amount*

Loan Information:

Requested loan amount*

Timeframe*

Detailed use of funds*

Have you applied with any bank, private lender or broker, in the past 30 days?*

If yes, with which companies?

Do you have any current business loans? (bank, government and/or private)*

If yes, please list the lender(s), loan amount(s) and approximate current balance(s)

Owner information:

Title / Prefix

First Name*

Last Name*

Home street address*

City/Town*

State/Province*

Country*

Zip/Postal Code*

Date of birth (MM/DD/YYYY)*

Title in business*

Ownership percentage (%)*

Email*

Cell / Daytime phone number*

Social Security / Social Insurance Number - Optional

Owner 2 - Required if Owner 1 is NOT 100% owner:

Please notify Owner 2 to look for an email sent automatically from JotForm, our documentation platform.

It will contain a link to COMPLETE & SIGN their portion of the application.

Title / Prefix

First Name*

Last Name*

Home street address

City/Town

State/Province

Country

Zip/Postal Code

Date of birth (MM/DD/YYYY)

Title in business

Ownership percentage (%)

Email*

Cell / Daytime phone number

Social Security / Social Insurance Number - Optional

Landlord / Mortgage company information - Optional, but may be necessary at time of funding:

Landlord / Mortgage company

Contact name

Phone number

Top supplier information - Optional, but may be necessary at time of funding:

Supplier company name

Contact name

Phone number

Supplier company name

Contact name

Phone number

Supplier company name

Contact name

Phone number

Emergency contact (can NOT be one of the owners):

Contact name*

Relation*

Phone number*

Special requests or instructions:

Please be as detailed as needed

QuiKap Funding is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you:

In order to provide you the content requested, we need to store and process your personal data. If you consent to us storing your personal data for this purpose, please tick the checkbox below.

You can unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy.

By signing below, the Merchant and its owner(s) certify that all information and documents submitted in connection with this Application are true, correct and complete. Additionally, the owner(s) authorize the Funder or any of its agents, partners, and affiliates to contact the above landlord, supplier, and emergency contacts, as well as obtain and use business and non-business consumer credit reports from credit reporting agencies and any other information regarding the Merchant and its owner(s) from third parties, both at the time of the initial funding application and at any time after the Merchant has received funding as long as the Merchant remains a client of the Funder. At all times, the Funder will comply with the personal information collection, protection, use, sharing, and retention practices set out in the Funders Privacy Policy.

Owner 1 - Signature (based on device, use mouse or finger to draw)*

Owner 1 - Full name*

Owner 1 - Date signed*

Date