BUSINESS FUNDING CLIENT INTAKE FORM

Thank you for your interest in funding with our company. Please use accurate information only when filling out this form. Please do not fill out this form if you are NOT located in the USA.

First Name *

Last Name *

Business Name *

Date of birth *

Phone *

Email *

State *

Personal Credit Scores *

Personal Credit Scores

Below 620
Between 620 - 699
Above 700
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Monthly Gross Revenue *

Monthly Gross Revenue

Less Than $5,000 / Mo
$5,000 - $10,000 / Mo
$10,000 - $20,000 / Mo
Above $20,000
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Collateral Owned By Business *

Collateral Owned By Business

Accounts Recievables
Investment Real Estate (Income Producing)
Business Owner Has 401K
No Collateral
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Do You Need Credit Repair? *

Do You Need Credit Repair?

Yes
No
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Do You Want To Build Business Credit? *

Do You Want To Build Business Credit?

Yes
No
Not Sure
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How Long Has Your Business Been Registered With The Secretary Of State?? *

How Long Has Your Business Been Registered With The Secretary Of State??

Less Than 2 Years
More Than 2 Years
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