BUSINESS INFORMATION

Legal / Corporate Name:

DBA:

Physical Address:

Physical Address

Street Address Line 2

CityState

Zip

Telephone #:

Fax:

Federal Tax ID:

Date Business Started:

Date

Length of Ownership:

Website:

Type of Entity (check one):

Email Address: *

example@example.com

Type of Business (check all that apply):

Product/Service Sold:

Corporate Officer/Owner Name:

Title:

Ownership %

Home Address:

Home Address

Street Address Line 2

CityState

Zip

SSN:

Date of Birth:

Date

Telephone #

Driver’s License #

Partner Name:

Title:

Ownership %

Home Address:

Home Address

Street Address Line 2

City:State:

Zip:

SSN:

Date of Birth:

Date

Telephone #*

Driver’s License #

Business Landlord or Business Mortgage Bank:

Contact Name and/or Account #

Phone #:

Monthly Mortgage Amount (if applicable):

Rent Amount:

Lease Expiration Date:

Date

Please describe the use of funds and how this financing will result in added benefit to your business. For working capital requests, please be as detailed as possible:

Please List any available collateral (Please also provide further details in a Facilities List, Personal Financial Statement, or Real Estate schedule):

Credit Card Processing Company:

Number of Terminals:

Terminal Type:

Requested Advance Amount:

Have You Taken a Cash Advance Before? (Please Check one)

YesNo

Requested Daily Withholding.

Monthly Volume:

Current Cash Advance Company (List All):

Cash Advance Balance(s):

By signing below, the Merchant and its owners and/or principals (individually and collectively, the “Applicant”) certifies that Applicant is authorized to submit this application on behalf of the above named business. Applicant certifies that all information and documents submitted in connection with this Application are true, correct and complete and may be relied upon by Federal National Funding LLC (“FNF”). Applicant shall immediately notify FNF of any material change in financial condition. Applicant authorizes FNF to share this application and all supporting documentation with each of its representatives, successors, assigns, and designees, including third party lenders (“Assignees”). Applicant further authorizes FNF and all Assignees to request, receive, and review any investigative or credit reports, including comprehensive business and personal credit histories or hard credit pulls, and any other information regarding the Applicant and its owners and/or principals from third parties deemed necessary by FNF or Assignees to verify any information provided on the Application and to investigate the references given on any other statement or data obtained from Applicant. Furthermore, Applicant hereby waives and releases any claims against FNF, all Assignees, and any information‐providers arising from any act or omission relating to the requesting, receiving or release of the information obtained in connection with this application. This authorization shall be valid for one hundred twenty (120) days unless revoked in writing by Applicant.

Applicant's Signature

Date

Applicant's Signature

Date

Upload 3 months recent bank statements

Upload copy of driver's license

BUSINESS INFORMATION

MERCHANT / OWNER INFORMATION

PARTNER INFORMATION