Applica

Step 1 of 2

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• Business Information

• Business Name*
• Business Phone*
• Do You Do Business Under A Different Name? (D.B.A.)*
• Type Of Legal Entity
  • Sole Proprietor
  • Partnership
  • Liability Company (LLC)
  • Corporation
• Gross Monthly Income*Select$5,000 – $24,999$25,000 – $49,999$50,000 – $199,999$200,000 – $499,999$500000+
• Amount Requested*SelectLess than $7,500 per month$7,500 – $9,999$10,000 – $19,999$20,000 – $29,999$30,000 – $39,999$40,000 – $49,999$50,000 – $59,999$60,000 – $69,999$70,000 – $79,999$80,000 – $89,999$90,000 – $99,999Over $100,000
• Business Address*
  Address
  
  City
  
  State
  AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific
  ZIP Code
  
  
• What part of the business do you have?
• Date Business Started
  
  Date Format: MM slash DD slash YYYY
  
• Do You Currently Have Another Short-Term Loan?*
• Federal TAX ID (federal only)

• Your Information

• Name*
  
  First
  
  Last
• DOB
  
  Date Format: MM slash DD slash YYYY
  
• Social Security number (SSN)*
• Contact Number*
• Email
  
• Home Address*
  Address
  
  City
  
  State
  AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific
  ZIP Code
  
  
• Upload account statements
  Drop files here or
  
  Accepted file types: jpg, png, pdf, docx.
• Signature*
• The Merchant and the Owner(s)/Officer(s) identified above (individually, an “Applicant”) represent, acknowledge and agree that (1) all information and documents provided to the representative (FUNDS), including statements from the credit card processor, is true, accurate and complete. (2) The applicant shall immediately notify FONDOS of any change in said financial condition information, (3) The applicant authorizes FONDOS to disclose all information and documents that the Representative may obtain, including credit reports, to other persons or entities ( collectively, “Assignees”) who may engage in or acquire business loans that have daily payment features or future receivables purchases, (6) the Applicant waives and releases any claim against the Recipients and any information providers arising from any act or omission related to the request, receipt or disclosure of information, and (7) each Owner / Official Representative who is authorized to sign this form on behalf of the Merchant. A copy of this authorization may be accepted as the original. The term “Representative” shall mean any financing source seeking to offer, make available, or provide Merchant with access to Merchant loans or cash advances based on said Merchant’s future accounts receivable or sales and/or structured with a periodic reimbursement function.
  I agree to the consent