EMPIRE STATE FINANCIAL

Legal business name*

DBA*

Entity*

EIN*

How long has your business been operating?*

Length of time your business has been open

Business Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Name*

First NameLast Name

Estimated credit score*

Ownership %*

Date Of Birth*

Date

Social Security Number*

Home Address*

Street Address

Street Address Line 2

CityState

Zip Code

How many funding positions do you currently have?*

Funder #1 Name*

Name of Funder #1

Funder #1 Approximate Balance*

Remaining balance owed to Funder #1

Funder #2 Name*

Name of Funder #2

Funder #2 Approximate Balance*

Remaining balance owed to Funder #2

Funder #3 Name*

Name of Funder #3

Funder #3 Approximate Balance*

Remaining balance owed to Funder #3

Fill in the names of your additional funders and approximate remaining balance on each*

Date of Application*

Date

Upload your 3 most recent business bank statements*

Upload your 4 most recent business bank statements

If you are applying on or after the 20th day of the month, upload this month's bank transaction history

Signature*

By signing above, each of the above listed business and business owner/officer (individually and collectively, “you”) authorize Empire State Funding and each of its representatives, successors, assigns and designees (“Recipients”) that may acquire or be involved with commercial funding having daily, weekly, monhly or other repayment features or purchases of future receivables including Merchant Cash Advance transactions, including without limitation the application therefore (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 Empire State Funding 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 agree to receive calls, texts, emails or mail from Empire State Funding or Recipients. You hereby waive and release any claims against Empire State Funding, Recipients, and any information-providers arising from any act or omission relating to the requesting, receiving, or release of information. You represent that you are authorized to sign this form on behalf of the listed business. You also consent to the release, by any creditor or financial institution, of any information relating to any of you, to Empire State Funding and to each of the Recipients, on its own behalf.

EMPIRE STATE FINANCIAL

Owner / Principal Information