Owner | Principal Information

Name

Social Security #

Date of Birth

Home Address

Do you own home? Please Select Yes No

More than 2 years? Please Select Yes No

Mobile

Email

% of Ownership

Annual Income

Value of Retirement, Bank & Brokerage Account

Driver License Number

State Of Issue

Select State Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY)

Expiration Date

Business Information

Business Description

Renter or Owned Please Select Renter Owned

Rent/Mortgage Amount

Landlord/Mortgage Company Contact

Open Bankruptcy? Please Select Yes No

Any Open Judgments? Please Select Yes No

Any Tax Liens? Please Select Yes No

Do you currently have any loans? If yes, what kinds and what is the balance?

Explain changes in Sales/Profit, or Debt (+/–10%)

How much Capital is being requested?

Repayment Terms Please Select Daily Weekly Monthly

Credit Card Montly volume

Total Monthly Sales (All Forms of Revenue)

Gross Annual Sales (Last year's Tax Return)

Number of Customers

What are your business growth plans for the next 3 to 5 years?

Broker? (Who referred you to us?)

By signing below, the Merchant and its owners/principals:

(1) I certify that all information and documents submitted in connection with this application are is (are) true, correct and complete.

(2) I authorize LNSGROUP LLC, its agents, and lenders to obtain & receive credit reports and other information regarding the Merchant and its owners and principals from third parties, to verify any information provided on this application.

(3) I authorize LNS Group LLC to obtain such information solely to prequalify me for credit options in connection with evaluating my eligibility for working capital and related financing solutions. Print Name

Date

Please upload:

• 3 current months Bank statements (all pages)
• Drivers License
• EIN Letter
• Corporate Formation Documents

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Note: All fields Are Required on this Application before Submission.

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