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General Information

Please provide some initial information on the next few pages so we can better serve your needs.
First Name is required
Last name is required
Business Name is required
E-mail is required
Phone Number is required
Desired loan amount is required

Eligibility

This answer is required.

Eligibility Continued

Confirmation

The Owner(s)/Officer(s) and Merchant identified above (individually, an “Applicant”) each represents,acknowledges, and agrees that (1) Applicant will immediately notify Fund-Ex Solutions Group, LLC (“FSG”) of anychange in the information or documents provided to FSG in connection herewith or Applicant’s financial condition,(2) each Assignee (as such term is defined in item (5) below) will rely upon the accuracy and completeness of such information and documents, (3) FSG, Assignees, and each of their representatives, successors, assigns and Designees (collectively, “Recipients) are authorized to request and receive any investigative reports, credit reports, statements from creditors or financial institutions, verification of or omission relating to the requesting, receiving or release of information, (5) Applicant authorized FSG to disclose all information and documents that FSG may obtain including credit reports to other personal, affiliates, partners or entities (collectively, “Assignees”) that may purchase FSG referral lists and/or marketing databases or be involved with or acquire FSG commercial loans, commercial loans having daily repayment features, and/or MerchantCash Advance transactions, including without limitation the application therefore (collectively, “Transactions”) and each Assignee is authorized to use such information and documents, and share such information and documents with other Assignees, in connection with potential Transactions, (6) all information and documents provided to FSG including credit card processor statements are true, accurate and complete, and (7) each Owner/Officer represents that he or she is authorized to sign this form on behalf of Merchant