On Q Funding Application

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1


On Q Funding Application


Corporation NameFull Legal Name
The Business DBA NameDBA
Federal ID#
Type of Business


Business Information


Address
City
State
Zipcode
Phone Number
Fax Number
Email Address


Financial / Credit Information


Dollar amount of monthly deposits into business bank account
Average daily bank balance
Business Start Date
Any Bankruptcies?
Any tax liens?
Product/Service Sold:
Average Ticket $
Cash Requested
Do you have a cash advance now:
With Who
Balance
Amount Taken
Total Payback
Daily Holdback
Date Taken
Average Monthly VISA/MC
Average Monthly Amex
Gross Annual Sales
Monthly Rent
Term on Lease
Franchise:


Owner Information (Owner/Officer/Partner)


Name
Date of Birth
S.S. #
% of Ownership
Address
City
State
Zipcode
Home Phone
Cell Phone
Do you own or rent?
Driver’s License #
Personal Email
Bank Name
Branch Address
Landlord
Phone Number

By signing below I/We certify the information above is true and understand that making false statements might be considered fraud. Applicant named above hereby authorizes On Q Funding its affiliates, assigns, agents, banks or financial institution to obtain an investigative report submitted by applicant for purpose of obtaining a working capital advance

I agree to these terms
Name
Title
Date
Name
Title
Date
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