App

A. Business Information

Legal/Corporate Name: *
DBA: *
Physical Address: *
City: *
State: *
Zip: *
Business Telephone: *
Fax #: *
Federal Tax ID: *
Contact Person: *
Email Address: *
Website: *
Date Business Started: *
Length of Ownership: *
Years at Location: *
# of Locations: *

B. Ownership

Name: *
Home Phone: *
Cell Phone: *
Home Address: *
City:*
State:*
Zip:*
Date of Birth:*
SS#:*
% Ownership of Company:*
Title:*
Driver’s License Number #:*
State Issued?:*

Partner Information:

Name:
Home Phone:
Cell Phone:
Home Address:
City:
State:
Zip:
Date of Birth:
SS#:
% Ownership of Company:
Title:
Driver’s License Number #:
State Issued?:

C. Bank Information

Name of Bank: *
Address: *
Contact: *
Phone: *

D. Landlord

Landlord Name: *
Contact: *
Cell Phone #: *
Work Phone #: *
Fax #: *

E. Trade Suppliers

Business Name: *
Contact: *
Phone #: *
Business Name: *
Contact: *
Phone #: *
Business Name: *
Contact: *
Phone #: *

F. Business Profile

Ownership: *

Merchant Type: *

Cards Accepted: *

Credit Card Processing: %

Card Swipe

Manual Key

Telephone

Mail Order

Internet

Must Total 100%

Monthly Amounts:

Total Sales *

Credit Card Process *

Rent Expense *

Goods Purchased *

Non-Owner Payroll *

Owners Draw/Salary *


How much would you like to borrow? *

What will you use the money for? *

How fast would you like to be funded? *


G. Signature

Applicant authorizes Speed Fund LLC., its assigns, agents, banks or financial institutions to obtain an investigative or consumer report from a credit bureau or a credit agency and to investigate the references given on any other statement or data obtained from applicant. Applicant, by signing below, represents that all the information is complete and accurate. Applicant waives and releases any claims against Recipients and any information-providers arising from any act or omission relating to the requesting, receiving or release of information. Owner/Officer represents that he or she is authorized to sign this form on behalf of Merchant.


Applicant’s Signature:
______________________
Date:
______________________
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