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PRE-QUALIFICATION FORM

Business Funding

CONTACT INFORMATION

BUSINESS INFORMATION

OWNER/PRINCIPAL INFORMATION

Co-owner Information

By signing below, each of the above listed business and business owner/officer (individually and collectively. "you") authorize Loan Broker 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 therefore (collectively, "Transactions") to obtain consumer 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 Loan Broker to transmit this application form, along 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 Loan Broker and to each of the Recipients, on its own behalf.

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