Application

We help businesses get the finances they need to succeed. We understand that obtaining funding can be an overwhelming process, which is why we're here to guide you every step of the way.

Our team of financial experts will work with you. Complete the application below and ensure that all necessary information is included. We'll then use our expertise to match you with the best funding options available, and help you get approved quickly.

FUNDING IN AS LITTLE AS 24HRS?

Legal Name:

DBA:

Business Established:

Business Address:

Mailing Address:

Tax ID:

Business Classification:

Business Phone:

Fax:

Best Number:

Email:

Website:

Rent

Past Bankruptcy?

Yes

Tax Liens or Judgements?

Yes

Landlord Contact Name:

Payment Plan?

Yes

Landlord Number:

Owner/Principal Name:

Owner/Principal Title:

% of ownership:

Home Address:

Home Phone:

Mobile Number:

Date of Birth:

Social Security #

Driver's License #

Driver's License State Issued:

Avg Monthly Card Sales $

Total Monthly Sales $

Annual Gross Sales $

Desired Pending Amount $

Use of Funds

Current Loan/Advance Balance? If Yes, Balance$

Held with

None Current

By signing below, each of the above listed business and business owner/oﬃcer (individually and collectively, “you”) authorize 5 Points Empire Inc. and each of its representatives, successors, assigns and designees (“Recipients”) that may be involved with or acquire commercial loans having daily repayment features or purchases of future receivables including Merchant Cash Advance transactions, including without limitation the application therefor (collectively, “Transactions”) to obtain consumer and/or personal, business and investigative reports and other information about you, including credit card processor statements and bank statements, from one or more consumer reporting agencies, such as TransUnion, Experian and Equifax, and from other credit bureaus, banks, creditors and other third parties. You also authorize 5 Points Empire Inc. to transmit this application form, with any of the foregoing information obtained in connection with this application, to any or all the Recipients for the foregoing purposes. You also consent to the release, by any creditor or ﬁnancial institution, of any information relating to any of you, to 5 Points Empire Inc. and to each of the Recipients, on its own behalf.

Signature

Print Name

Date

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