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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
*
Select
Less 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 - $99,999
Over $100,000
Business Address
*
Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed 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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed 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
