Business Verification Form
ONLY TAKES 3 MINUTES!
Business Legal Name
*
Business DBA Name
*
Address
*
Business Address
Street Address Line 2
City
State
Zip
Contact
*
Phone
*
Format: (000) 000-0000.
Cell Phone
*
Format: (000) 000-0000.
Fax
Website
Email
*
example@example.com
Tax ID (TIN) #
*
Time In Business (Current Owner)
*
Industry Type / Detailed Description:
*
Type of Business Entity (LLC, Sole Prop, Corp, Partnership) & State of Incorporation
*
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Owner(s) / Officers(s) Information
Name (Primary Owner)
*
Title
% of Ownership
*
Date of Birth
*
/
Month
/
Day
Year
Date
SSN#
*
Home Address
*
City
*
State
*
Zip
*
Home Phone
Format: (000) 000-0000.
2nd Owner?
2nd Name (2 Owner)
Title
% of Ownership
Date of Birth
/
Month
/
Day
Year
Date
Home Address
City
Zip
SSN#
Home Phone
Format: (000) 000-0000.
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Funding Information – REQUIRED
Gross Annual Revenue
Average Monthly Bank
Use of Proceeds
Do you have any open contracts for working capital at this time? If ‘Yes’ list the working capital provider and balance
Signature
*
Primary Owner Signature: Print Name
*
Date
*
/
Month
/
Day
Year
Date
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Please upload the last 6 months of business bank statements (November 2025 - April 2026)
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