Funding Application | Legacy Financial Marketing

Business Information

Legal Business Name*

DBA Name

Type of Business

Federal Tax ID

Organization Type

Years in Business

Business Email

Phone

Address

Street Address Address Line 2 City State ZIP Code

Billing Address (if different)

Street Address Address Line 2 City State ZIP Code

Financial Information

Requested $ Amount

Average Ticket Price

Average Monthly V/MC

Average Monthly AMEX

Gross Annual Sales

Current CC Processor

Do you have a cash advance?

Yes

Owner/Officer Information

If there are more than 3 owners/officers, add them in the Additional Notes section near the bottom of this form.

Number of Owners/Officers*

More than 3

Owner/Officer 1

First Name

Last Name

SSD

Birth Date

Percent of Ownership

Home Phone

Mobile Phone

Personal Email

Home Address

Street Address City State ZIP Code

Own or Rent Home?

Own

Rent

Years There

Drivers License Number

Drivers License State

Owner/Officer 2

First Name

Last Name

SSD

Birth Date

Percent of Ownership

Home Phone

Mobile Phone

Personal Email

Home Address

Street Address City State ZIP Code

Own or Rent Home?

Own

Rent

Years There

Drivers License Number

Drivers License State

Owner/Officer 3

First Name

Last Name

SSD

Birth Date

Percent of Ownership

Home Phone

Mobile Phone

Personal Email

Home Address

Street Address City State ZIP Code

Own or Rent Home?

Own

Rent

Years There

Drivers License Number

Drivers License State

Business Location

Lease or Own?

Lease

Own

Term on Lease

Monthly Rent/Mortgage

Landlord or Mortgage Company

Landlord Contact Name

Contact Work Phone

Contact Mobile Phone

Landlord Email

References

Bank Name & Branch

Bank Contact Name

Bank Contact Phone

Trade Reference 1 Name

Trade Reference 1 Contact

Trade Reference 1 Phone

Trade Reference 2 Name

Trade Reference 2 Contact

Trade Reference 2 Phone

Trade Reference 3 Name

Trade Reference 3 Contact

Trade Reference 3 Phone

Other

Are there any pending, threatened or recently filed claims judgments or liens?

Yes

Are you contemplating a bankruptcy filing? Reorganization? Sale of the Business?

Yes

Required Files

Please upload your three (3) most recent Bank Statements Maximum total size: 40 MB Allowed file types: pdf, jpg, jpeg, gif, png

Upload Files

Drop files here or

Max. file size: 40 MB.

Authorization

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 Legacy Financial Marketing 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 (Owner/Officer 1)*

Signature (Owner/Officer 2)*

Signature (Owner/Officer 3)*