FUNDING APPLICATION
Amount Requested ($):
Desired Payback Period:
Use of Funds:
SECTION 1— BUSINESS INFORMATION
Legal Business Name *
*
DBA (if different)
Business Phone *
*
Format: (000) 000-0000.
Business Fax
Business Email *
*
example@example.com
Physical Street Address (no P.O. Box) *
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State *
*
ZIP Code
County
Years at Location
Business Website
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Entity Type:
Sole Proprietor
Partnership
LLC
S-Corp
C-Corp
Non-Profit
Other
Federal Tax ID (EIN) *
*
Date Business Established (MM/DD/YYYY) *
*
-
Month
-
Day
Year
Date
State of Incorporation
Industry / Type of Business *
*
Number of Employees
Number of Locations
Products / Services Sold
SECTION 2 – OWNER / GUARANTOR INFORMATION
Owner 1
First Name
Middle Initial
Last Name
Ownership % *
*
Home Address *
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone *
*
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Email Address
example@example.com
Social Security Number *
*
Date of Birth (MM/DD/YYYY) *
*
-
Month
-
Day
Year
Date
Has Owner 1 filed for bankruptcy in the past 7 years?
Yes
No
Any outstanding judgments or tax liens?
Yes
No
Owner 2
First Name
Middle Initial
Last Name
Ownership % *
Home Address *
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Email Address *
example@example.com
Social Security Number *
Date of Birth (MM/DD/YYYY) *
-
Month
-
Day
Year
Date
Has Owner 2 filed for bankruptcy in the past 7 years?
Yes
No
Any outstanding judgments or tax liens?
Yes
No
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MERCHANT CASH ADVANCE Funding Application (continued)
Page 2 of 2
SECTION 3 — EXISTING ADVANCES / BUSINESS DEBT
Does the business have any existing MCAs or business loans?
Yes
No
SECTION 3 — EXISTING ADVANCES / BUSINESS DEBT
Rows
Lender / Funder Name
Original Amount ($)
Balance Owed ($)
Daily / Weekly Pymt ($)
Maturity Date
1
2
SECTION 4 — TERMS, CONDITIONS & APPLICANT REPRESENTATIONS
The Merchant and Owner(s)/Officer(s) identified above (individually, an "Applicant") each represents, acknowledges and agrees to all of the following terms and conditions:
1. Accuracy of Information.
All information and documents provided to Representative, including credit card processor statements, are true, accurate and complete. Applicant shall immediately notify Representative of any change in such information or financial condition.
2. Disclosure & Assignment Authorization.
Applicant authorizes Representative to disclose all information and documents that Representative may obtain — including credit reports to other persons or entities (collectively, "Assignees") that may be involved with or acquire commercial loans having daily repayment features or purchases of future receivables, including Merchant Cash Advance transactions, including without limitation the application therefor (collectively, "Transactions"). Each Assignee is authorized to use such information and documents, and to share such information and documents with other Assignees, in connection with potential Transactions.
3. Reliance on Information.
Representative and each Assignee will rely upon the accuracy and completeness of all information and documents provided by Applicant. Applicant acknowledges that any material misrepresentation or omission may result in the immediate termination of any funding arrangement and may subject Applicant to legal liability.
4. Authorization to Obtain Investigative & Credit Reports.
Representative, Assignees, and each of their representatives, successors, assigns and designees (collectively, "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 a Recipient deems necessary in connection with the evaluation or administration of any potential Transaction.
5. Waiver & Release of Claims.
Applicant waives and releases any and all claims against Recipients and any information-providers arising from any act or omission relating to the requesting, receiving, or release of information in connection with this application or any Transaction, to the fullest extent permitted by applicable law.
6. Authority to Execute.
Each Owner/Officer executing this application represents and warrants that he or she is duly authorized to sign this form on behalf of the Merchant, and that such execution creates a valid and binding obligation of the Merchant enforceable in accordance with its terms.
7. Copies as Originals.
A copy, facsimile, electronic, or digital reproduction of this authorization and application may be accepted as and deemed an original for all purposes, including enforcement.
8. Definition of "Representative".
The term "Representative" shall mean any funding source looking to offer, make available, or provide to the Merchant access to loans or merchant cash advances based on such Merchant's future receivables or sales and/or structured with a periodic repayment feature, including but not limited to daily, weekly, or monthly repayment schedules.
9. No Commitment to Fund.
Submission of this application does not constitute a commitment by Representative or any Assignee to provide financing. All funding decisions are subject to final underwriting approval, verification of information, execution of definitive agreements, and satisfaction of all applicable conditions.
10. Governing Law.
This application and any Transaction arising herefrom shall be governed by and construed in accordance with applicable law. Any disputes arising in connection with this application shall be resolved in accordance with the terms of the definitive funding agreement executed between the parties.
SECTION 5 — AUTHORIZATION & SIGNATURE
By signing below, I/we certify that all information provided in this application is true, complete, and accurate to the best of my/our knowledge. I/we authorize the funding company and its representatives to verify any and all information provided herein, including obtaining consumer and/or business credit reports. I/we confirm that I/we have read, understand, and agree to all Terms and Conditions set forth in Section 4 above. I/we understand this is not a commitment to fund and that all funding is subject to final approval.
Signature — Owner / Guarantor 1
Date
-
Month
-
Day
Year
Date
Title / Position
Print Name - Owner / Guarantor 1
Signature — Owner / Guarantor 2 (if applicable)
Date
-
Month
-
Day
Year
Date
Title / Position
Print Name - Owner / Guarantor 2
This application is for informational purposes only and does not constitute a binding agreement or commitment to lend.
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