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1. Company Information

Business Legal Name *

Classification

Time in Business

Main Phone *

Fax

Physical Street Address *

City

State

Zip Code *

Federal Tax ID#

2018 Sales

Website

Is physical and billing address different?
Yes No

Billing Street Address

City

Zip Code

Industry type:

Business Location

Amount (Monthly)

Landlord Name

Landlord Phone

2. Financial Information

Use of Proceeds

Current Credit Card Processor:

Average Monthly Credit Card Volume:

Amount Requested

Equipment Vendor Name

Vendor Contact Name

Phone Number

Total Estimated Equipment Cost

Equipment To Be Financed or Leased

Current Working Capital Loan?
Yes No

Lender Name

3. Principal Information (Personal Information of Proprietors, Partners or Major Shareholders)

Owner 1

First Name *

Middle Name

Last Name *

Title

Home Address

City

State

Zip Code

Ownership % *

Home Phone

Cell Phone*

Date of Birth

SSN*

Email *

"Draw Signature with FINGER"

Owner 1 Signature

Clear

Signature Date

Owner 2

First Name

Middle Name

Last Name

Title

Home Address

City

State

Zip Code

Ownership %

Home Phone

Cell Phone

Date of Birth

SSN

"Draw Signature with FINGER"

Owner 2 Signature

Clear

Signature Date

Owner 3

First Name

Middle Name

Last Name

Title

Home Address

City

State

Zip Code

Ownership %

Home Phone

Cell Phone

Date of Birth

SSN#

"Draw Signature with FINGER"

Owner 3 Signature

Clear

Signature Date

Owner 4

First Name

Middle Name

Last Name

Title

Home Address

City

State

Zip Code

Ownership %

Home Phone

Cell Phone

Date of Birth

SSN#

"Draw Signature with FINGER"

Owner 4 Signature

Clear

Signature Date

4. Bank Information

Bank Name

ABA/Routing Number

Account Number

5. Other Information

Any judgments/liens?

Yes No

Any open bankruptcies?
Yes No

Is this a home based business?
Yes No

Is your business seasonal?
Yes No

If yes, what are peak months?

Business Trade Reference #1

Phone

Business Trade Reference #2

Phone

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