US EXPRESS FUNDING

MADE IN USA
Referred By
BUSINESS INFORMATION
Legal Business Name
DBA if different
Date Business Established MMDDYYYY

MonthDayYear
Date
Mailing Address
Physical Address
Business Fax
Business phone
Mobile
EMail
example@example.com
Website
Tax ID Number or Business Number
Business property own or lease
Landlord Mortgage Company Name
Landlord/ Mortgage Company Name and hone: Has the business or any principal ever filed for Bankruptcy Protection?
Pending rent or mortgage payments. Recently file claims against owner ?
Years in Control
Landlord Contact Name
OWNER/PRINCIPAL INFORMATION
Name
Home Address
Title
of Ownership
Cell Phone
Cell Phone
EMail
example@example.com
Drivers License #
Date of Birth MMDDYY

MonthDayYear
Date
Social Security
Drivers License State
OWNER/PRINCIPAL INFORMATION
Name
Home Address
Title
of Ownership
EMail Address
example@example.com
Cell Phone
Drivers License #
Date of Birth MMDDYY

MonthDayYear
Date
Social Security
Drivers License State
COMPANY INFORMATION
Average Monthly cards sales $ :
Total monthly sales : $
Annual Gross sales : $
Desired Funding Amount : $
Use of Funds :
Current loan or advance :
Balance
Held With
Owner Principal Signature

Clear
CoOwner CoPrincipal Signature

Clear
Print Name
Print Name
I/we ( Business owners(s) / Principal (s) , hereby authorize the release of any and all information pertaining to my/our business known as: (Legal Name of Business / DBA), as requested by US EXPRESS FUNDING any of their affiliates, agents, representatives in connection with my/our application. This General Authorization also serves as instruction to any person to release the requested information, including but not limited to: deposit accounts, merchant accounts, payment cards processing accounts, credit references/verifications, payment history, balance, status, etc.

The undersigned hereby consent(s) to US EXPRESS FUNDING to obtain and use non-business consumer credit reports on the undersigned in order to further evaluate the undersigned as pricipal(s), member(s), partner(s), proprietor(s) and/or guarantor(s) and to obtain and use business information from, but not limited to, credit report bureaus, Dun & Bradstreet or its equivalent, public records, UCC or PPSA Holders, banks, financial institutions, landlords, vendors, suppliers, etc.

I/we attest that the information submitted in the application is correct to the best of my/our knowledge and has been submitted voluntarily.

A photocopy or facsimile of this authorization shall be deemed to be the equivalent of an original.
Legal name of business / DBA
Business Name
Business address
Business Phone
Owner Principal Print Name
Owner Principal Signature

Clear
Owner Principal Signature

Clear
Date

MonthDayYear
Date
Date

MonthDayYear
Date
US EXPRESS FUNDING
PLEASE ANSWER THE FOLLOWING QUESTIONS
How many employees do you have W2
of Business Ownership
Do you pay yourself a salary from the business W2
If yes , how much is your annual salary ?
Do you have any outstanding business debts ? :
Do you own or rent your home
How long have you lived at the current address?
Mortgage payment or rent payment amount per month ?
Value of your personal cash balances ?
Type aValue or personal retirement balance ( 401k , IRA, Pension etc) question
Stock , bonds or securities value ?
Please list business debt with Creditor name , balance , monthly payments , original date , credit limit and use of funds.
Current balance on loan or advance : $
Current loan or advance held with whom ?
Should be Empty:

MADE IN USA

BUSINESS INFORMATION

OWNER/PRINCIPAL INFORMATION

OWNER/PRINCIPAL INFORMATION

COMPANY INFORMATION

US EXPRESS FUNDING