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APPLY NOW
APPLICATION
Step 1 of 6
16%
BUSINESS INFORMATION
Business Legal Name
*
First
Last
Other Business Name / DBA (If any):
First
Last
Is the Business Incorporated/ Organized/ Registered?
Yes
No
EIN:
Business Type:
Corp / S Corp
LLC
LLP
LP
GP
Sole Proprietorship
Date Registered:
Date Format: MM slash DD slash YYYY
State
Full Mailing Address (HQ /Home Office):
City:
State:
Zip Code:
Phone:
Fax:
Your email address:
*
Describe your business:
APPLYING SHAREHOLDER / DIRECTOR / OFFICER / MEMBER / PARTNER
Full Name:
First
Last
SSN:
Full Home Address:
City:
State:
Zip Code:
Home:
Rent
Own
Home Phone:
Cell Phone:
Position (Check all that apply):
Owner
CEO
CFO
Director
Officer
Shareholder
Member
Partner
Other:
Ownership / Voting Percentage:
Driver’s License Number (If holding more than 20%):
IS BUSINESS CURRENT WITH:
Federal and State Income Tax:
Yes
No
If NO, amount in arrears: $
State and Local Sales Tax?
Yes
No
If NO, amount in arrears: $
Employee Deductions:
Yes
No
If NO, amount in arrears: $
BANKING INFORMATION
Company Bank:
How long with this bank?
Bank Mailing Address:
City:
State:
Zip Code:
Account Number:
Bank Officer:
Phone Number:
COMPANY ACCOUNTS
Total Accounts Receivable: $
Average Monthly Sales? $
Approximate Number of Active Customers
Terms of Sale:
Is the business discounting / factoring receivables now or in the past?
First Choice
Second Choice
Third Choice
If yes, with what company?
Are receivables pledge as collateral?
Yes
No
If yes, to whom?
What amount do you plan to sell monthly? $
The undersigned hereby warrants that all of the above information is true and correct in every aspect. The undersigned further hereby warrants that all financial statements accurately represent in every respect, the true and correct financial condition of the parties that are the subject of this application. The undersigned hereby authorizes Midwest Business Funding to gather and use, from time to time, without the undersigned’s knowledge, any and all financial and/or credit information relating to the business entity that is the subject of this application that can be obtained from any source whatsoever including, but not limited to, banks, trade associates and creditors. The undersigned also hereby authorizes Midwest Business Funding to investigate the personal credit history of the undersigned and obtain credit bureau reports on the undersigned from time to time at Midwest Business Funding’s sole discretion
