BUSINESS FUNDING INTAKE FORM
Input your information to the best of your knowledge to ensure providing your financial intake needs.
CONTACT NFORMATION
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
BUSINESS INFORMATION
Business Name
*
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Structure
*
Please Select
LLC
Nonprofit
Corporation
Sole Proprietorship
Other
Please select your business structure
Industry Type of Business
*
Business Start Date
-
Month
-
Day
Year
Date
Annual Revenue
Please Select
Under $50k
$50k-$100k
$100k-$500k
$500k+
FUNDING REQUEST
Amount of Funding Request
*
Please enter an estimate
Purpose of Funding
*
Equipment
Marketing
Expansion
Working Capital
Debt Consolidation
Other
When do you need the funds?
*
Please Select
Immediately
30 Days
60 Days
90+ Days
CREDIT & DOCUMENATION
Current Personal Credit Score Range
*
Please Select
300-579
580-669
670-739
800+
Do you have an Active Business Bank Account
Please Select
Yes
No
Do you have an EIN?
*
Please Select
Yes
No
Are your Business Taxes Up-to-Date
*
Please Select
Yes
No
Upload the last 3 months of bank statements, tax returns, or business plans
Browse Files
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AUTHORIZATION & AGREEMENT
“I authorize KSSG Legacy Wealth Group to review my information for the purpose of securing business funding.”
Signature
*
Date
*
-
Month
-
Day
Year
Date
Request Funding Now
Request Funding Now
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