Application – FundQube

A. Business Information

Legal/corporate name

DBA (if different from legal name)

Physical address

Is mailing address different from physical address?

Yes No

Mailing address

Federal tax ID

Business Phone

Alternate Phone

Is there a preferred business contact other than owner?

Yes No

Contact Name

Contact Email

Contact Phone

Website

Date Business Started

Length of Ownership

# of Locations

Years at Location

B. Ownership

Owner First Name

Owner Last Name

Business Phone

Alternate Phone

Home Address

Drivers license #

SSN

Date of Birth

% Ownership of Company

Is there a co-owner?

Yes No

Please Enter Co-Owner's Details Bellow

First Name

Last Name

Home Phone

Cell Phone

Home Address

Drivers license #

SSN

Date of Birth

% Ownership of Company

C. Business Profile

Ownership

Sole Proprietorship Corporation Partnership LLC

Industry

Average gross monthly sales

D. Existing Business Funding

Do you have existing business financing?

Yes No

Existing financing #1

Existing financing #2

Existing financing #3

Existing financing #4

E. Business Bank Statements

3 months business bank statements

Acceptance

Authorization to contact you by phone: You authorize us, and our affiliates, agents, and independent contractors, to contact you at any telephone number you provide to us or from which you place a call to us, or any telephone number where we believe we may reach you, using any means of communication, including, but not limited to, calls or text messages to mobile, cellular, wireless or similar devices and calls or text messages using an automated telephone dialing system and/or artificial voices or prerecorded messages, even if you incur charges for receiving such communications. Authorization to Contact You By Other Means: You also agree that we and our affiliates, agents and independent contractors may use any other medium, as permitted by law and including, but not limited to, mail, e-mail and facsimile, to contact you.

F. Signature and Authorization to Obtain Information

Acceptance

By signing below, the Merchant and its owners/principals each: (1) certify that all information on and documents submitted in connection with this Pre-qualification Request are true, correct, and complete; and (2) acknowledge that the owners/principals are personally liable for Merchant; and (3) provide authorization and ‘written instruction’ to Credibly under the Fair Credit Reporting Act to obtain information from your personal and/or business credit profile as well as additional information from credit bureaus and other sources. This authorization and written instruction is to obtain information solely to conduct a pre-qualification for business funding, verify provided information and report fraudulent transactions. If you are requesting pre-qualification on-line, clicking “I AGREE” shall be written instructions with the same effect as your signature.

Owner Signature

Co-Owner Signature

Today's date

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You’re Pre Approved!

Business Funding Request

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