By signing below, you certify that all information and documents submitted in connection with this application are true, correct, and accurate. Incomplete applications will not be processed.

Funding Application

Business Legal Name


DBA Name


Business Address

Suite/Floor

City


State or Province

Zip


US County


Main Business Phone


Fax


Business Website


Merchant Email Address


Federal State Tax # or PAN Card#


Legal Structure: (Click One)


Merchant Type: (Click One)

Business Location Type: (Click One)

Date Business Started
*

Use Of Loan Proceeds?


Declared Bankruptcy In The Last 7 Years?

Do You Have Any Tax Liens?

Have Any Judgments?

Is Your Business Seasonal?

Do You Rent or Own Your Home?


Number of Years Lived There?


Are You A US Citizen?


Products / Services Sold

Business Landlord/Mortgage & References

TRADE REFERENCE 1:
Name


Phone



BANK REFERENCE :
Name

Phone

LANDLORD/MORTGAGE COMPANY:
Company Name


Do You Rent or Own Your Business Location?

RENT/MORTGAGE PAYMENT:
Monthly Payment (number only)

Owner/Principal Information

This business has Owner(s) With 51% or More Ownership

Name

Title

Address

City


State or Province

Zip

Phone

Email


% of Ownership (Must Be 51% Owner)


Date of Birth
*

SSN#

Annual Income


Driver's License # and State of Issue

Funding Information

Does Your Business Accept Credit Cards?

Gross Annual Revenues:
Loan Amount Requested

Have You Used A Cash Advance Plan Before?

Average Bank Balance:

By signing below, each of the above listed business and business owner/officer (individually and collectively, "you") authorize YOUR BUSINESS NAME HERE and each of its representatives, successors, assigns and designees ("Recipients") that may be involved with or acquire commercial loans having daily 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 also authorize YOUR BUSINESS NAME HERE 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. You also consent to the release, by any creditor or financial institution, of any information relating to any of you, to YOUR BUSINESS NAME HERE and to each of the Recipients, on its own behalf. You expressly consent to receiving emails and text messages, as well as any live or prerecorded telephone calls, including to your mobile phone, regarding loan options. You can opt-out from receiving further communications from YOUR BUSINESS NAME HERE by emailing optout@mainstreetbusinessloan.com


Owner

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