WP E-Signature by Approve Me - Sign Documents Using WordPress -

FUNDING APPLICATION

To apply for business funding, please fill out the application accurately and to the best of your ability. At the end of the form, you must upload three (3) PDFs of your most recent bank statements. Once the required fields are complete, you will be prompted to digitally sign the document.

BUSINESS INFORMATION

BUSINESS NAME:*

DBA NAME:

PHYSICAL ADDRESS:*

MAILING ADDRESS:*

BUSINESS PHONE:*

BUSINESS FAX:

TYPE OF ENTITY:*

TAX ID:*

BUSINESS START DATE:*

# OF LOCATIONS:

BUSINESS PROPERTY TYPE:*

MONTHLY RENT/MORTGAGE:

LANDLORD/BANK NAME:

LANDLORD/BANK CONTACT:

LANDLORD/BANK PHONE:

ANNUAL GROSS SALES:*

AMOUNT REQUESTED:

USE OF FUNDS:*

EXISTING ADVANCE:*

IF SO, WITH WHO:

CURRENT BALANCE:

OWNERSHIP INFORMATION

PRINCIPAL OWNER NAME:*

OWNERSHIP %:*

SSN#:*

D.O.B.:*

HOME ADDRESS:*

PHONE:*

E-MAIL:*

PRINCIPAL OWNER NAME:

OWNERSHIP %:

SSN#:

D.O.B.:

HOME ADDRESS:

PHONE:

E-MAIL:

CREDIT CARD PROCESSING INFORMATION

CURRENT CC PROCESSOR:

MID:

ANNUAL CC SALES:

AVG MONTHLY CC VOLUME:

Disclaimer: 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 Representative including credit card processor statements are true, accurate and complete, (2) Applicant will immediately notify Representative of any change in such information or financial condition, (3) 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 therefore (collectively, "Transactions"), and each Assignee is authorized to use such information and documents, and share such information and documents with other Assignees, in connection with potential Transactions, (4) Representative and each Assignee will rely upon the accuracy and completeness of such information and documents, (5) 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, (6) Applicant waives and releases any claims against Recipients and any information‐providers arising from any act or omission relating to the requesting, receiving or release of information, and (7) each Owner/Officer represents that he or she is authorized to sign this form on behalf of Merchant. A copy of this authorization may be accepted as an original. 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.

April 27, 2024

To complete your application, please provide 3 months of bank statements.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

July 26, 2018 3:00 pm EDT

FUNDING APPLICATION Uploaded by Joseph Pak - jp@vitalfundingsolutions.com IP 68.98.116.57

July 27, 2018 1:19 pm EDT