Funding Application

Email: funding@protinuscapital.com

Phone: 904 419 9931

145 Beachwalk Shore Drive STE 102-113

St. Johns, FL 32259
Business Legal Name:
Doing Business As:
Legal Entity:
Federal Tax ID:
Business Phone:
Format: (000) 000-0000.
Business Website:
Mobile:
Format: (000) 000-0000.
Business Fax:
Email Address:
example@example.com
Business Start Date:

MonthDayYear
Date
Physical Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Funding Application
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner
Name:

First NameLast Name
% of Ownership:
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Mobile:
Format: (000) 000-0000.
Date of Birth:

MonthDayYear
Date
SSN:
2nd Owner (If Applicable)
Name:

First NameLast Name
% of Ownership:
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Mobile:
Format: (000) 000-0000.
Date of Birth:

MonthDayYear
Date
SSN:
Business Information
Business Description:
Renter or Owned:
Any Bankrupcies?
Rent/Mortgage Amount:
Landlord/Mortgage Company Contact:
Funding Information
Amount Requested?
Use of funds?
Monthly Sales
Annual Sales (Last Year):
Do you currently have any open fundings? If Yes, what is the current balance?
Authorization Form
The Business and Owner(s) above (individually, and/or collectively, represents, acknowledges and agrees that (1) all informationand documents provided to EX Management Services LLC DBA Protinus Capital on this application are true, accurate and complete, (2) Applicant will immediately notify Protinus Capital of any changes in such information or financial condition, (3) Applicant authorizes Protinus Capital and its third-party funding partners, which includes lenders and other finance providers with whom Protinus Capital has, or may in the future enter into, commercial-brokerage-financing relationships ("Recipients"), to use, share and disclose all information and documents that any Recipient may obtain induding credit reports to other persons or entities, this application, (4) All Recipients may rely upon the accuracy and completeness of such information and documents, (5), All Recipients are authorized to request and receive any investigative reports, credit reports, statements from creditors or financial institutions, verification of information, or any other information that said Recipients deem necessary, (6) All Recipients may contact Applicant via e-mail, call and/or text-message at the e-mail address and/or phone number provided above, or at any e-mail address and/or phone number reasonably identified as belonging to Applicant, including wireless numbers (if applicable), even if listed on a Do-Not-Call registry, using an automated telephone dialing system or other similar system with respect to this application, future-related commercial-financing opportunities and/or other lawful telemarketing purposes, (7) Applicant waives and releases any claims against Recipients and any information-providers arising from any act of omission relating to the requesting, receiving or release of information, and (8) Applicant represents that he or she is authorized to sign this form on behalf of the Business.
Owner Signature:
Co-Owner Signature:
Print Name:
Print Name
Date:

MonthDayYear
Date
Date:

MonthDayYear
Date
Should be Empty:

Funding Application

Owner

2nd Owner (If Applicable)

Business Information

Funding Information

Authorization Form