PRE-QUALIFICATION FORM

Pre-Qualification Form
Amount Requested
Use of Funds
Current Advance/Loan Balance & Name
Business Legal Name
Business D/B/A Name
Annual Revenue
State of Incorporation
Fed Tax ID #
Entity Type
Home-Based Business
Industry Type
Business Phone
Format: (000) 000-0000.
Business Start Date

MonthDayYear
Date
Website
Owner Email
Owner / Officer #1
Owner Full Name

First NameLast Name
Title
Ownership %
Date of Birth

MonthDayYear
Date
Credit Score
SSN
Cell Phone
Format: (000) 000-0000.
Home Address

street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Is there a 2nd Owner?
Owner / Officer #2
Owner Full Name

First NameLast Name
Title
Ownership %
Date of Birth

MonthDayYear
Date
SSN
Credit Score
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Authorization & E-Signature
Authorizations: The Merchant and Owner(s)/Officer(s) identified above (individually, an "Applicant") each represents, acknowledges, and agrees that (1) all information and documents provided to Encore Business Funding ("EBF") are true, accurate, and complete, (2) Applicant will immediately notify EBF of any change in such financial condition, (3) EBF and its affiliates 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 EBF deems necessary, (4) Applicant waives and releases any claims against EBF and any information-providers arising from any act or omission relating to the requesting, receiving, or release of such information, and (5) each Owner/Officer represents that he or she is authorized to sign this form on behalf of Merchant.
Owner/Officer Signature #1
Printed Name (Owner /Officer #1)
Date

MonthDayYear
Date
Owner/Officer Signature #2
Printed Name (Owner /Officer #2)
Please upload 4 months of business bank statements *Minimum 20k per month

Cancelof
Should be Empty:

Pre-Qualification Form

Owner / Officer #1

Owner / Officer #2

Authorization & E-Signature