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Merchant Application
Business Information
Type of Business Entity
*
Corporation
Limited Liability Company
Partnership
Limited Partnership
Limited Liability Partnership
Sole Proprietor
Business Legal Name:
*
State of Incorporation:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Business DBA Name:
*
EIN #:
*
Business Address
Physical Street Address:
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Business Phone #:
*
Cell Phone #:
*
Business Type: (Description)
*
Business Start Date:
*
Funding Amount Requested: ($)
*
Gross Annual Sales: ($)
*
Use of Proceeds:
Ownership Information - Owner 1
Ownership %:
*
Primary Merchant Email:
*
Name
*
Name
Last Name
Last Name
First Name
First Name
Social Security Number
*
Date of Birth
*
Credit Score:
Street Address:
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Ownership Information - Owner 2
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Ownership %:
Secondary Merchant Email:
Name
Name
Last Name
Last Name
First Name
First Name
Social Security Number
Date of Birth
Credit Score:
Address:
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Authorization and Certifications:
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.
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Owner / Officer 1 Signature:
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Owner / Officer 2 Signature:
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