FUNDERA CAPITAL APPLICATION

FUNDERA CAPITAL
BUSINESS FUNDING PRE-QUALIFICATION APPLICATION
BUSINESS INFORMATION
Business Legal Name
Business DBA Name if applicable
Type of Business Entity
State of Incorporation
Business Street Address
City
State
ZIP Code
Industry
Business Phone Number
Fax if applicable
Website if applicable
Business Federal Tax ID EIN
Monthly Rent / Mortgage Payment (Mortgage Paid in Full):
Business Start Date (Under Current Ownership): (MM/DD/YYYY)

MonthDayYear
Date
Time in Business
Gross Annual Sales: (Based on most recent tax return or trailing 12 months)
FUNDING REQUEST
Amount Requested
BUSINESS OWNER INFORMATION
Legal First Name
Legal Last Name
Social Security Number
Date Of Birth

MonthDayYear
Date
City
State
ZIP Code
Home Phone
Mobile Phone
Email Address
example@example.com
EQUIPMENT INFORMATION
(Only if purchasing equipment)
Equipment Type Model
Equipment Cost ($):
Equipment Description
Vendor Name
Vendor Contact
Address

Vendor Street Address

Street Address Line 2

CityState

Postal / Zip Code
ZIP Code
AUTHORIZATION & DISCLOSURES
The Business and the Business Owner(s) identified above (each an "Applicant") represent, acknowledge, and agree as follows: 1. All information provided in this application and any supporting documentation is true, accurate, and complete.

2. Applicant agrees to immediately notify Fundera Capital of any material change to the information or financial condition provided.
3. Applicant authorizes Fundera Capital to obtain, verify, and share personal and business information, including credit reports, bank information, and application materials, with lenders, funding partners, assignees, and third-party service providers for the purpose of evaluating and facilitating potential financing transactions, including but not limited to:

Equipment Financing or Leasing

4. Applicant authorizes Fundera Capital, its partners, and service providers to rely upon the accuracy of the information submitted.

5. Applicant authorizes the request and receipt of credit reports, bank verifications, and investigative reports as necessary.

6. Applicant releases Fundera Capital, its partners, and service providers from liability arising from the collection, use, or sharing of such information.

7. Applicant consents to being contacted via phone, email, SMS, or automated dialing systems, including numbers listed on any Do-Not-Call registry.

8. Applicant understands that consent to communication is not a condition of purchase.

9. The undersigned certifies they are authorized to sign on behalf of the business and any listed owners.

10. Applicant consents to the collection, use, and disclosure of personal and business information in accordance with Fundera Capital's Privacy Policy and applicable law.
SIGNATURE
Business Owner Name Print
Business Owner Signature

Clear
Date MMDDYYYY

MonthDayYear
Date
Should be Empty:

FUNDERA CAPITAL

BUSINESS INFORMATION

FUNDING REQUEST

BUSINESS OWNER INFORMATION

EQUIPMENT INFORMATION

AUTHORIZATION & DISCLOSURES

SIGNATURE