Funding App

1
How much do you need?
2
What's your average monthly revenue?
less then > $8,000
$8,000 - $15,000
$15,000 - $30,000
$30,000 - $55,000
$55,000 - $75,000
$75,000 - $125,000
$125,000 - $255,000
$255,000 - $375,000
$375,000 - $500,000
$500,000 and above
3
What's the total annual revenue?
less then > $24,000
$25,000 - $74,000
$75,000 - $154,000
$155,000 - $295,000
$300,000 - $695,000
$700,000 - $2,995,000
$3mm - $6mm
$7mm - $10mm
$10mm and above
4
Which best describes your business?
Agriculture & Forestry/Wildlife Extermination/Pest Control
Farming(Animal Production)
Farming(Crop Production)
Fishing/Hunting
Landscape Services
Lawn care Services
Other (Agriculture & Forestry/Wildlife)
Business & Information Consultant
Employment Office
Fundraisers
Going out of Business Sales
Marketing/Advertising
Non Profit Organization
Notary Public
Online Business
Other (Business & Information)
Publishing Services
Record Business
Retail Sales
Technology Services
Telemarketing
Travel Agency
Video Production
Construction/Utilities/Contracting AC & Heating
Architect
Building Construction
Building Inspection
Concrete Manufacturing
Contractor
Engineering/Drafting
Equipment Rental
Other (Construction/Utilities/Contracting)
Plumbing
Remodeling
Repair/Maintenance
Education Child Care Services
College/Universities
Cosmetology School
Elementary & Secondary Education
GED Certification
Other (Education)
Private School
Real Estate School
Technical School
Trade School
Tutoring Services
Vocational School
Finance & Insurance Accountant
Auditing
Bank/Credit Union
Bookkeeping
Cash Advances
Collection Agency
Insurance
Investor
Other (Finance & Insurance)
Pawn Brokers
Tax Preparation
Food & Hospitality Alcohol/Tobacco Sales
Alcoholic Beverage Manufacturing
Bakery
Caterer
Food/Beverage Manufacturing
Grocery/Convenience Store(Gas Station)
Grocery/Convenience Store(No Gas Station)
Hotels/Motels(Casino)
Hotels/Motels(No Casino)
Mobile Food Services
Other (Food & Hospitality)
Restaurant/Bar
Specialty Food(Fruit/Vegetables)
Specialty Food(Meat)
Specialty Food(Seafood)
Tobacco Product Manufacturing
Truck Stop
Vending Machine
Gaming Auctioneer
Boxing/Wrestling
Casino/Video Gaming
Other (Gaming)
Racetrack
Sports Agent
Health Services Acupuncturist
Athletic Trainer
Child/Youth Services
Chiropractic Office
Dentistry
Electrolysis
Embalmer
Emergency Medical Services
Emergency Medical Transportation
Hearing Aid Dealers
Home Health Services
Hospital
Massage Therapy
Medical Office
Mental Health Services
Non Emergency Medical Transportation
Optometry
Other (Health Services)
Pharmacy
Physical Therapy
Physicians Office
Radiology
Residential Care Facility
Speech/Occupational Therapy
Substance Abuse Services
Veterinary Medicine
Vocational Rehabilitation
Wholesale Drug Distribution
Motor Vehicle Automotive Part Sales
Car Wash/Detailing
Motor Vehicle Rental
Motor Vehicle Repair
New Motor Vehicle Sales
Other (Motor Vehicle)
Recreational Vehicle Sales
Used Motor Vehicle Sales
Natural Resources/Environmental Conservation Organizations
Environmental Health
Land Surveying
Oil & Gas Distribution
Oil & Gas Extraction/Production
Other (Natural Resources/Environmental)
Pipeline
Water Well Drilling
Other Other(Business Type Not Listed)
Personal Services Animal Boarding
Barber Shop
Beauty Salon
Cemetery
Diet Center
Dry cleaning/Laundry
Entertainment/Party Rentals
Event Planning
Fitness Center
Florist
Funeral Director
Janitorial/Cleaning Services
Massage/Day Spa
Nail Salon
Other (Personal Services)
Personal Assistant
Photography
Tanning Salon
Real Estate & Housing Home Inspection
Interior Design
Manufactured Housing
Mortgage Company
Other (Real Estate & Housing)
Property Management
Real Estate Broker/Agent
Warehouse/Storage
Safety/Security & Legal Attorney
Bail Bonds
Court Reporter
Drug Screening
Locksmith
Other (Safety/Security & Legal)
Private Investigator
Security Guard
Security System Services
Transportation Air Transportation
Boat Services
Limousine Services
Other (Transportation)
Taxi Services
Towing
Truck Transportation(Fuel)
Truck Transportation(Non Fuel)
5
What purpose would your loan serve? Select all that apply:
Expanding
Working Capital
Payroll
New Equipment
Purchase a Business
Buy Out Partner
Real Estate
Start a Business
6
Business Legal Name:
7
Business DBA:*If Applicable
8
Business Address: (P.O. Box, Not Accepted)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Business Start Date:
Date
Year
Month
Day
10
Business Tax ID / EIN:
11
What type of entity is your business?
LLC
Sole Proprietor
Corporation
Legal Partnership
12
Where is your business located?
Home Based
Own - Free & Clear
Mortgage
Rent/ Lease
13
Let's learn a little about your business. Select all that apply:
Accept Credit Cards
Invoice Customers
Seasonal
Had a Bankruptcy
Non-Profit
Any Tax Liens / Judgments
14
Let's learn a little about your business. Select all that apply:
Accept Credit Cards
Invoice Customers
Seasonal
Had a Bankruptcy
Non-Profit
Any Tax Liens / Judgments
15
Any Existing or Current Business Funding Balances?
YESNO
16
Existing or Current Funding Details?Lender Name, Funded Amount, Current Payments.....
17
Business Owner Name:
First Name
Last Name
18
Best Phone Number:
19
Best Email Address:
20
Home Address: (P.O. Box, Not Accepted):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
21
Ownership Percentage %:
10%
20%
30%
49%
50%
51%
60%
70%
80%
90%
100%
22
Date of Birth:
Date
Year
Month
Day
23
Social Security Number:
24
Any Additional Owners?
YESNO
25
2nd Owner Name:
First Name
Last Name
26
2nd Owner Phone Number:
27
2nd Owner Email:
28
2nd Owner Home Address: (P.O. Box, Not Accepted):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
29
2nd Owner Ownership Percentage %:
10%
20%
30%
49%
50%
51%
60%
70%
80%
90%
100%
30
2nd Owner Date of Birth
Date
Year
Month
Day
31
2nd Owner Social Security Number:
32
Upload: Last 3 Months Business Bank Statements Last 3 Months of Merchant Statements
Drag and drop files here
Select files to upload
Cancelof
33
* This field is required.Terms and ConditionsBy signing below, each of the above listed business owner/officer (individually and collectively. “You”) authorize Genesis Merchant Services, Inc. and each of it’s representatives, successors assignees and designees (“Recipients”) that may be involved with or acquire financing including daily repayment features or purchases of future receivables including Merchant Cash Advance transactions, including without limitation the application therefor (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 Exuifax, and from other bureaus, banks, creditors and other third parties. You also authorize Genesis Merchant Services, Inc to transmit this application form, along with any of the foregoing information obtained in connection with this application, to any or all of 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 Genesis Merchant Services, Inc. and to each of the Recipients, on it’s own behalf.
34
Business Owner Signature
35
2nd Business Owner Signature
Should be Empty: