Web Application

APPLICATION
Business Information
Type of Entity:
If Other, Describe.
Business Legal Name:
DBA:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Federal Tax ID:
Business Start Date:
State of Inc:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Website:
What does your company do:
Owner #1 Ownership %:
Full Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Social Security Number
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Owner #2 Ownership %:
Full Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Social Security #
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Credit / Revenue
Approximate, Credit Score:
Average Gross Deposits Per Month
Gross Annual Sales: (Previous Year Tax Return)
Amount Requested:
Use of Funds:
Existing Advance
Loan 1 Balance:
Company:
Payment Amount, Frequency
Loan 2 Balance:
Company:
Payment Amount, Frequency
Property Information
Own or Rent
Landlord / Mortgage Co.:
Contact:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Rent / Mortgage Amount:
Are You Current?
If not, how much owed?
Questions
Are there any pending claims, judgments, tax liens, UCC-1's, bankruptcies against the Merchant or any Principal?
If Yes, Please Explain
Authorization
By signing this Application, the Merchant and it's owners/principals: (1) certify that all information and documents submitted in connection with this are true, correct and complete; and (2) authorize Bluerock Financing LLC., it's agents, partners, and lenders to receive credit reports and any other information regarding the Merchant and it's owners and principals from third parties, to verify any information provided on the Application
If you are working with a Broker, their name.
Signature Owner #1
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature Owner #2
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

APPLICATION

Business Information

Credit / Revenue

Existing Advance

Property Information

Questions

Authorization