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1
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2
50%
Business Information
Gross monthly income
$5,000 - $24,999
$25,000 - $49,999
$50,000 - $199,999
$200,000 - $499,999
$500,000+
Amount Requested
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 Name
Do You Do Business Under A Different Name? (D.B.A.)
Business Address
Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip
Business Phone
(Required)
Type of legal entity?
Sole Proprietor
Partnership
Liability Company (LLC)
Corporation
Date Business Started
MM slash DD slash YYYY
Do You Currently Have Another Short-Term Loan?
Federal TAX ID (federal only)
Ownership %
Personal information
Name
First
Last
Social Security number (SSN)
DOB
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Cellphone
(Required)
E-mail
(Required)
Home Address
Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip
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Signature
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Consent
(Required)
I agree to the consent.
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.
96828
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