Business Owner Information

Business Legal Name

Business DBA

Type of Business
—Please choose an option—Corp.LLCSole PropPartnership

Business Start Date under Current Ownership, MUST BE GREATER THAN 1 YEAR

Business Tax ID

Business Street Address

City

State
—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

Home Based Business?
YesNo

Do you accept Credit Cards
YesNo

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Owner Information

Owner 1 First Name

Owner 1 Last Name

Social Sec #

Date of Birth

Ownership %

Home Address

City

State
—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Estimate Your Credit
—Please choose an option—Good (700 – 850)Fair (600 - 700)Poor (500 – 600)Very Poor (400-500)

Any open Judgements or liens?
YesNo

Have You applied for a bank loan?
YesNo

Any open bankruptcies?
YesNo

How many NSF / Insufficient fund days?
01-55-10

By checking above, each of the above listed business owners/officers (individually and collectively, “you”) authorize Formula Funding (“FF”) and each of its partners, representatives, investors, successors, assigns and designees (“Recipients”) that may be involved with or acquire commercial funding having daily, weeky, or monthly repayment features or purchases of future receivables including merchant cash advance transactions, including without limitation the application therefore (collectively, “Transactions”) to obtain consumer or personal, business and investigative reports and other information about you, including credit card processor statements and bank statements, from one or more consumer reporting agencies, such as TransUnion, Experian and Equifax, and from other credit bureaus, banks, creditors and other third parties. You authorize FF to transmit this application form, along with any of the foregoing information obtained in connection with this application, to any or all of the Recipients for the foregoing purposes and without limitation or restriction. You also consent to the release, by any creditor or financial institution, of any information relating to any of you, to FF and to each of the Recipients, on its own behalf.

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