Business Information

Ownership Information




Banking Information

Landlord

Trade References

Business Profile

Ownership

Merchant Type

Cards Accepted

Credit Card Processing

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%
%
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Monthly Sales Amount

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$
$

Applicant(s) authorizes Bankers Capital Funding, its assigns, agents, banks or financial institutions to obtain an investigative or consumer report from a credit bureau or a credit agency and to investigate the references given on any other statement or data obtained from applicant. Applicant, by signing below, represents that all the information is complete and accurate. The Merchant and Owner(s)Officer(s) identified above (individually, an “Applicant”) each represents, acknowledges and agrees that (1) all information and documents provided to Representative including credit card processor statements are true, accurate and complete. (2) Applicant will immediately notify Representative of any change in such information or financial condition. (3)Applicant authorizes Representative to disclose all information and documents that Representative may obtain including credit reports to other persons or entities (collectively,(“Assignees”)) that may be involved with or acquire commercial loans having daily repayment features or purchases of receivables including Merchant Cash Advance transactions, including without limitation the application therefore (collectively, “Transactions”),and each Assignee is authorized to use such information and document and share information and documents with other Assignees in connection with potential Transactions.(4)Representative and each Assignee will rely upon the accuracy and completeness of such information and documents.(5)Representative, Assignees, and each of their representatives, successors, assigns and designees (collectively, “Recipients”) are authorized to request and receive any investigative reports, statements from creditors or financial institutions, verification of information, or any other information that a Recipient deems necessary.(6)Applicant waives and releases any claims against Recipients and any information-providers arising from any act or omission relating to the requesting, receiving or release of information and(7)each Owner/Officer represents that he or she is authorized to sign this form on behalf of Merchant. A copy of this authorization may be accepted as an original. The term “Representative” shall mean any funding source looking to offer, make available, or provide to the Merchant access to loans or merchant cash advances based on such Merchant future receivables or sales and/or structured with a periodic repayment feature.