alternative business funding word administrative form022015 .pdf

ADMINISTRATIVE FORM
FAX TO: NEW CONTRACTS 206-415-2208

Sales Rep: Miguel Morales

The BusinessDBA Name:

Legal Name:

Type of Business:
Bus. Address:
Billing Address (if different)
Phone at Location:
Bus. Email:
Years in Business:

Fed ID#:
City / State / Zip:
City / State / Zip:
Preferred Phone:
Website:

Do You Have a Cash Advance?:
Avg Monthly V/MC $:
Current Credit Card Processor:

With Who?:
Avg AMEX:

Corp / LLC/ Sole Prop

Fax:
Average Ticket $:

Owners / Officers1st Owner Name:

Date of Birth:

Balance:
Gross Annual Sales:

SS#:

Home Address:
Home Phone:

City / State / Zip:
Cell Phone:

Own / Rent

Drivers Lic#:

State:

Personal Email:

2nd Owner Name:
Home Address:
Home Phone:
Drivers Lic#:

Date of Birth:
City / State / Zip:
Cell Phone:
State:

Business Location:
Lease or Own:
Landlord or Mortgage Co:
Email:
References:
Bank Name:
Trade #1
Trade #2
Trade #3

Term on Lease:
Contact:

Branch:

Phone:
Phone:
Phone:
Phone:

Yrs There:

SS#:
Own / Rent
Personal Email:

Yrs There:

Monthly Rent:
Phone#
Cell#:

Contact:
Contact:
Contact:
Contact:

Are there any pending, threatened or recently filed claims judgments or liens?
Are you contemplating a bankruptcy filing? Reorganization? Sale of the Business?
I hereby represent that all the above information is true and understand that making false statements might be considered fraud. By providing the
above information, the applicant(s) authorize you to whom this application is made or your agents to investigate my/our financial responsibility and
credit worthiness, specifically principal and corporate entities, and will provide financial statements, tax returns, etc. as you deem necessary. A
photocopy of this authorization will be deemed as acceptable for release of credit information. I/we authorize Strategic Funding Source, Inc. to
receive pertinent information regarding the commercial lease for the above referenced location from my leasing company and or agent. I/we

authorize you to update my/our credit profile from time to time in the future, as you deem appropriate.

Signature #1:
Date:

Signature #2:
Date: