ADMIN FORM

    Applicant/Owners Personal Information

    Agents Name: *

    Full Name *

    Email *

    Phone Number *

    Date of Birth *

    SSN Number *

    Address (No PO Boxes) *

    Have you ever declared bankruptcy? *

    YesNo

    Do you owe any taxes for the current or previous tax years? *

    YesNo

    Do you have any claims or lawsuits? *

    YesNo

    Do you own or rent your primary residence? *

    YesNo

    Company Information

    What kind of business do you have? *

    Legal Business Name *

    Doing Business As (DBA)

    Type of Business *

    EIN Number or Tax Number

    Business Phone Number *

    Business Inception Date *

    Business Address (No PO Boxes) *

    Shareholder #1 Name *

    Percentage Owned *

    Shareholder #2 Name (if applicable)

    Percentage Owned

    Website (leave blank if not applicable)

    Gross Annual Business Revenue *

    Average Bank Balance *

    Desired Loan Amount *

    Number of Deposits Per Month *

    Desired Term Length *

    Do You Have A business Checking Account? *

    YesNo

    Do You Have an Outstanding Merchant Cash Advance? *

    YesNo

    Do you accept more than 50% of your sales on your card? *

    YesNo

    Do you rent or own your business building? *

    YesNo

    Landlord Name (if renting)

    Landlord Phone # (if renting)

    Owner #2 Information (if applicable)

    Full Name

    Email

    Phone Number

    Date of Birth

    SSN Number

    Address (No PO Boxes)

    Have you ever declared bankruptcy?

    YesNo

    Do you owe any taxes for the current or previous tax years?

    YesNo

    Do you have any claims or lawsuits?

    YesNo

    Do you own or rent your primary residence?

    YesNo

    Supporting Documents Upload

    Optional - First Month Business Bank Statements:

    Optional - Second Month Business Bank Statements:

    Optional - Third Month Business Bank Statements:

    Optional - Present Month to Date Business Bank Statements:

    Optional - Copy of DL:

    Optional - Copy of Business Account VOIDED CHECK:

    “The personal information may be gathered and used by a third party and its assignees and potential assignees, to provide products and to perform services as may be requested by you. We may also disclose your personal information to third parties such as the manufacturer of your vehicle, credit reporting agencies, financial institutions of financing companies, your insurance agent or company and/or companies which provide or insure warranties relating to your vehicle. You are entitled to access this personal information that you provide and you may ask that it be updated and rectified. I acknowledge that the information, including personal information, may be processed and stored outside of the United States. We may also disclose your personal information where we are permitted by law to do so. By signing this document below, you have consented to these uses and disclosures.”

    Date:


    Owner #1 Signature *
    Date:


    Owner #2 Signature