Merchant Cash Advance Application Funding #BLX6190 1. Company Information Full Legal Business Name Doing Business as (DBA)

Landlord/MTGE Company: Rent/MTGE Monthly Contact Name: Phone #

Business Address City State Zip Phone # Fax # Cell # E-Mail Address:

( ) - ( ) - ( ) -

Company Type: Corporation Individual/Sole Proprietorship Partnership Limited Liability Company Other: Date Business Started: Federal Tax ID: State of Incorporation: Products / Services Sold: Average Yearly MC/Visa/Discover Volume: Requested Amount: Terminal Model: Rent/Own/or Lease Pin Pad Model: American Express Merchant ID:

Prior / Current Cash Advance Company: Amount: Balance:

2. Owner Information Name: (First, MI, Last) Title Phone # ( ) -

Home Address City State Zip

Social Security # D.O.B.: % Ownership:

3. Trade Reference

Trade Reference 1: Contact Name: Contact Telephone:

Trade Reference 2: Contact Name: Contact Telephone:

The above information is warranted to be true and complete. We hereby authorizes Business Loan Xchange its assigns, agents, bank, or financial institution to verify and collect information on us, including but not limited to bank references, trade credit references, and/or commercial credit reports. In compliance with the FAIR CREDIT REPORTING ACT, this is to inform you that you are authorizing this organization and / or its suppliers to obtain a consumer and / or business profile credit report. ______________________________________ ____________________________________________ ___________________________ Sign Name Print Name Date