Pre-Qualification Authorization
Business Information
Business Legal Name:
*
Business DBA Name:
Business Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone:
*
Format: (000) 000-0000.
Website:
Business Email:
*
example@example.com
Tax ID:
*
Start Date:
*
-
Month
-
Day
Year
Date
Business Description:
*
Business Entity:
*
Corp
LLC
LLP
Partnership
Sole Prop
Owner(s) Principal(s) Information
Name (Primary Owner):
*
Title:
*
% of Ownership:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
SSN:
*
Drivers License #
*
State of Issue:
*
Housing Status:
*
Own Home:
Rent:
Address:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email:
*
example@example.com
Phone:
*
Format: (000) 000-0000.
Additional Owner/Partner
Name:
Title:
% of Ownership:
Date of Birth:
-
Month
-
Day
Year
Date
SSN:
Drivers License #
State of Issue:
Housing Status:
Own Home:
Rent:
Address:
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email:
example@example.com
Phone:
Format: (000) 000-0000.
Signature(s)
Please date and sign below
By my/our signature on this Application, either as a principal of the applicant or personal guarantor of applicant's obligations, I/we hereby declare under the penalty of perjury that all information contained in this Application and all financial information I/we provide is true, correct and complete as of the date it is being submitted to Shalev Capital (Creditor) or its designee. I/We understand that Creditor is relying upon this document and upon the information contained in it for the purpose of extending, modifying or renewing credit. I agree to inform Creditor immediately of any change or deterioration in the information or values stated herein. I/we authorize Shalev Capital, or its designee (and any assignee or potential assignee thereof), to verify any of the information from whatever source it deems appropriate, which authorization shall extend to obtaining and review of my/our personal credit profile from a national credit bureau in considering this Application and subsequently for the purpose of update, renewal or extension of such credit or additional credit and for reviewing or collecting the resulting account. ECOA NOTICE: If this Application for business credit is denied, you have the right to a written statement of the specific reasons for denial. To obtain the statement, contact David@shalevcapital.com within 60 days from the date you are notified of our decision. We will send you a written statement of the reasons for the denial within 30 days of receiving your request for the statement. NOTICE: The Federal Equal Opportunity Act prohibits creditors from discriminating against applicants on the basis of race, color, religion, national origin, sex, marital status, or age (provided the applicant has the capacity to enter into a binding contract); or because all or a part of the applicant's income derives from any public assistance program or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is the Federal Trade Commission, Equal Credit Opportunity, Washington, D.C. 20580. A Copy or Facsimile of this Agreement with Signature shall be Considered to be an Original.
Type Name (Primary Owner):
Primary Owner Signature:
Date:
-
Month
-
Day
Year
Date
Type Name (Additional Owner/Partner):
2nd Owner Signature:
Date:
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: