Web Application

APPLICATION
Business Information
CorporationGeneral PartnershipLLCLPSole PropLLPS CorpNon ProfitOther
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
Date
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
Date
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
OwnLeaseHome Based
Landlord / Mortgage Co.:*
Contact:*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Rent / Mortgage Amount:*
YesNO
If not, how much owed?
Questions
YesNO
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
Date
Signature Owner #2
Date:

MonthDayYear
Date
Should be Empty:

APPLICATION

Business Information

Credit / Revenue

Existing Advance

Property Information

Questions

Authorization