EMPIRE FUNDING & CAPITAL SOLUTIONS

BUSINESS FUNDING APPLICATION

Who Referred You? *

Requested Funding Amount *

Purpose of Funding? *

PERSONAL INFORMATION

First Name

Last Name

Email *

Phone *

Address *

Street Address

City

State

Country

Postal code

Date of Birth *

Social Security Number *

1. Write all sources of provable income 2. How much do you receive monthly? 3. How long have you been receiving it? *

1. Have you, spouse, or parent served in the military? If yes, what branch? Please state your status. Or, do you currently bank with any of the military banks i.e. Navy Federal, USAA, or Pen Fed etc? *

SETUP CREDIT MONITORING TO VIA

TRIMERGE CREDIT SCORES

www.creditchecktotal.com or www.identityiq.com

Username *

Password *

Go to profile and setup a security question and answer. What's the security question? *

What's the security answer? It's case sensitive, so enter EXACTLY the way you typed it? *

Pin# *

Experian Score? *

Equifax Score? *

TransUnion Score? *

Which Credit Monitoring service are these credentials for?

BUSINESS INFORMATION

Name of your company/organization *

Indicate if company is incorporated. If so, indicate the type, and indicate how old your company. *

What's your last two years business revenue. Indicate your gross and net income for the last two years? Indicate if you have/will be filing with IRS. *

Do you have a business checking account? If yes, What's your average monthly deposits in your business bank account for the last 12 months. If no, indicate last 12 months personal average deposits in your personal checking account and let us know its personal not business. *

Does the company have business credit? If so, what's the current business credit score. *

Please list all credit in the business name. Name of account, type of account, credit limit, monthly payments, any lates.

List any/all collateral i.e. real estate property, savings, stocks, IRAs, other bank accounts etc. If no, put: N/A *

Feel free to add any additional details relevant to this questionnaire.

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

All information submitted is true and accurate and does not contain any intentional false information.