Please fill in ALL fields below. By doing so, you are giving Your Discount Funding Company, as well as its agents and affiliates, permission to review your business and personal history in order to provide you with formal approval
First Name: __________________________________________
Last Name: ______________________________________
Company: ______________________________________
Company DBA: ______________________________________
Company Address: ______________________________________
______________________________________
Email Address: ______________________________________
Phone Number: ______________________________________
Fax Number: ______________________________________
Cell Number: ______________________________________
Company Description: ______________________________________
Website: ______________________________________
Federal Tax Number: ______________________________________
Business Start Date: ______________________________________
Entity: p Corp p Sole Prop p LLC p Partnership
Type: p Retail p Restaurant p Service p Internet
Location: p Store Front p Office p Home p Other
Landlord name ________________________________
Landlord phone # ________________________________
Rent/Mortgage Amount: $ ________________________________
Is this business Seasonal? ______
Additional comments or anything else we should know; ________________
_______________________________________________________________
Current Cash Advance Company: ______________________________
Original Amount: $__________________________
Amount Owed: $__________________________
Payment Amount: %_____ or $__________________________
Any other open Cash Advances? _______________________________
Average gross monthly sales $__________________________
Average gross monthly credit card sales: $______________
Any Returned Checks? ______ How Many______________
Do You Have An Open Bankruptcy: p Yes p No
Do You Have An Open Tax Lien: p Yes p No
Are you on a payment plan? ____ $__________________
Approximated Credit Score: ____________
Amount Requesting? $ _____________________________
Purpose of Funds: ________________________________________
Owner/Principal Information
| Owner Name: __________________________________________ |
| Address: ______________________________________________ |
| City, State, Zip: _________________________________________ |
| Phone: ________________________________________________ |
| Email: ________________________________________________ |
| % Ownership: __________________________________________ |
| Date Of Birth: __________________________________________ |
| SSN#: __________________ Driver #: ______________________ |
| Co-Owner Name: _______________________________________ |
| Address: ______________________________________________ |
| City, State, Zip: _________________________________________ |
| Phone: ________________________________________________ |
| Email: ________________________________________________ |
| % Ownership: __________________________________________ |
| Date Of Birth: __________________________________________ |
| SSN#: __________________ Driver #: ______________________ |
Business Reference #1 __________________________ Phone _____________
Business Reference #2 __________________________ Phone _____________
Business Reference #3 __________________________ Phone _____________
By signing below the Merchant and its owners/principals: (1) certify that all information and documents submitted in connection with this Application is true, correct and complete; and (2) Your Discount Funding Company, partners, and lenders to receive credit reports and any other information regarding the Merchant and its owners and principals from third parties, to verify any information provided on the Application.
Signature(s) Required
| Signature Borrower: ______________________ | Signature Co-Borrower: ____________________ |
Print Name ____________________ Print Name _____________________
Date: ______________________ Date: ____________________
Please print and fax to (828)333-7014