Merchant Application - Sal

Fortifi Capital

Business Information

Tell us about your business

Type of Business Entity *

Business Legal Name *

State of Incorporation *

Business DBA Name *

EIN # *

Physical Street Address *

City *

State *

Zip Code *

Business Phone # *

Cell Phone # *

Business Type (Description) *

Business Start Date *

Funding Amount Requested ($) *

Gross Annual Sales ($) *

Use of Proceeds

Please complete all required fields above to continue.

Ownership Information

Provide details for each owner/officer

1 Owner / Officer 1

First Name *

Last Name *

Ownership % *

Primary Merchant Email *

Social Security Number *

Date of Birth *

Credit Score *

Street Address *

City *

State *

Zip Code *

2 Owner / Officer 2

First Name *

Last Name *

Ownership % *

Primary Merchant Email *

Social Security Number *

Date of Birth *

Credit Score *

Street Address *

City *

State *

Zip Code *

Please complete all required fields above to continue.

Authorization & Documents

Upload documents and sign below

Upload Documents

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By signing below, the above listed business and owner(s)/officer(s) (individually and collectively "you") authorize Fortifi Cap (“FC”) and each of its representatives, successors, assigns, designees and any third-party funders or financial institutions that may be involved with, acquire, or make commercial loans and/or purchases of future receivables (“Recipients”) to obtain consumer/personal and business investigative and/or credit reports from one or more consumer credit reporting agencies and other information about you, including credit card processor statements, bank statements and verifications of information from banks, creditors and other third-parties. You also authorize FC to transmit this application form, along with any of the foregoing information obtained in connection with this application, to any or all of the Recipients for the purposes of securing you working capital. You also consent to the release by any creditor or financial institution of any information relating to you to FC and to each of the Recipients. You certify that you are authorized to submit this application on behalf of the above-named business and that all information provided in this application and in connection therewith is true, accurate and correct.

Owner / Officer 1 Signature *

Draw your signature above

Owner 1 signature is required.

Owner / Officer 2 Signature *

Draw your signature above

Owner 2 signature is required.