Business Funding Application

Complete the application details, upload the required documents, and review the authorizations before signing.

Basic Business Information

Legal Business Name

DBA / Trade Name

Business Structure

EIN:

Federal Tax ID

Date Business Started

Years / Months in Business

Industry / NAICS Code

Business Phone

Business Email

Website

Address

Physical Address

Country

State / Province

City

Postal Zip / Code

Funding Request Details

Amount Requested

Purpose of Funds

Desired Term / Repayment Preference

Primary Owner / Principal Information

Full Legal Name

First

Middle

Last

Title / Position

Date of birth

Ownership Percentage

Social Security #

Personal Phone

Personal Email

Home Address

Home Address Line 2

Home City

Home State

Home Zip Code

Financial & Banking Information

Primary Business Bank

Account Type

Account Number

Routing Number

Average Monthly Revenue (Last 3 Months)

Liens, Judgements, or Bankruptcies?

Yes

No

Current Outstanding Business Debts/Loans

Creditor

Balance

Monthly Payment

Creditor 2

Balance 2

Monthly Payment 2

Creditor 3

Balance 3

Monthly Payment 3

Do you have additional outstanding debts or loans?

Yes

No

Merchant / Processing Information

Primary Processor

Monthly Processing Volume

Average Ticket Cost

Max Ticket Cost

Est. Monthly Processing Volume

Percentage of Sales Paid Now/Delivered Later *

Online Purchases? *

Yes

No

Recurring Subscription Billing *

Yes

No

Refund Policy *

No Refund

Exchange Only

Store Credit

Partial Refund

Full Refund

Percentage Paid Via: *

Online
In Person
Over the Phone

Please ensure total = 100%

Additional Notes / Feedback

Share any additional notes here:

Required Documents Checklist

Driver's License or State ID (Front)

Driver's License or State ID (Back)

Voided Business Check

Bank Statements - Most Recent 3 Months

Processing / Merchant Statements - Most Recent 3 Months

Authorizations & Certifications

I agree to all authorizations and certifications. Read Authorization Disclosure HERE.

Printed Name

Title

Today's Date

Signature

Clear