60 SECOND BUSINESS FUNDING APPLICATION

First Name:  *

Last Name:  *

Primary Number:  * Only Digits

Office Home Cell

* Email:  * Not a valid email

60 SECOND BUSINESS FUNDING APPLICATION

Company Name:  *

Time in Business: Please Select Business Not Started Purchasing Existing Business 0 - 5 Months 6 - 12 Months 1 - 2 Years 2 - 3 Years 3 - 4 Years 4 Years or More

Do you accept credit cards? Yes No  *

Average monthly bank deposits: Please Select 0 - 14 15 - 30 30 - 50 50 or 100 100+

Would you like to begin accepting credit cards? Yes No

60 SECOND BUSINESS FUNDING APPLICATION

Home-Based Business? No Yes

Type of Business:

Monthly Gross Sales:

Last 4 Months Avg. Bank Account Balance:

60 SECOND BUSINESS FUNDING APPLICATION

Amount Requested:

When would you like funds wired to your account? Please Select ASAP 0-1 Week 0-2 Weeks 2-3 Weeks 3-4 Weeks 30-60 Days 60-90 Days

Your Personal Credit Score: Please Select 500 525 550 575 600 625 650 675 700 725 750 775 800 825 850

Best time to call: Please Select Morning Afternoon Evening Weekends Only

60 SECOND BUSINESS FUNDING APPLICATION

Time in Business: Please Select Purchasing Existing Business Business Not Started 1 - 3 Months 3 - 6 Months 6 - 12 Months 1 - 2 Years 2 Years or More

Monthly Credit Card Sales:

Average Monthly Gross Sales: Please Select $5,000 - $10,000 $10,000 - $20,000 $20,000 - $50,000 $50,000 - $75,000 $75,000 - $100,000 $100,000 - $250,000 $250,000 or More

Type of Business:

Special Offers Just For You (Select all that apply)