Asset 14
Business
Auto Repair and Mechanic
Beauty, Hair and Nail Salon
Convenience Store
Dentist
Healthcare & Medical
Hotel
Pizzeria
Restaurant
Retail
Spa & Health Club
Finance
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Company Information
*
Business legal name
Business dba name
*
Tax ID
*
Physical street address
*
City
*
State
*
Zip Code
*
Physical location phone
Preferred contact phone
Fax number
*
Company website
*
Company email address
*
Industry type
ie: Automotive, Finance, Entertainment, etc.
*
State of incorporation
The state/region where your business is registered
*
Year Started
Year of registration
*
Type of business entity
Corporation
Limited Liability Company
Partnership
Limited Partnership
Limited Liability Partnership
Sole Proprietor
*
Desired working capital
$5,000 - $10,000
$10,000 - $25,000
$25,000 - $50,000
$50,000 - $100,000+
Owner Information
*
Owner 1 full name
*
Owner 1 percentage
*
Owner 1 social security number
*
Owner 1 date of birth
January
February
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*
Owner 1 street address
*
Owner 1 city
*
Owner 1 state
*
Owner 1 zip code
*
Owner 1 email
*
Owner 1 phone
+Add Additional Owner
Owner 2 full name
Owner 2 percentage
Owner 2 social security number
Owner 2 date of birth
January
February
March
April
May
June
July
August
September
October
November
December
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Owner 2 street address
Owner 2 city
Owner 2 state
Owner 2 zip code
Owner 2 email
Owner 2 phone
*
I agree to the following terms
The Merchant and Owner(s)/Officer(s) identified above (individually, an “Applicant”) each represents, acknowledges and agrees that (1) all information and documents provided to Claremont Advance, Inc. (hereinafter CAI) including credit card processor statements are true, accurate and complete, (2) Applicant will immediately notify CAI of any change in such information or financial condition, (3) Applicant authorizes CAI to disclose all information and documents that CAI may obtain including credit reports to other persons or entities (collectively, “Assignees”) that may be involved with or acquire commercial loans having daily repayment features or purchases of future receivables including Merchant Cash Advance transactions, including without limitation the application therefor (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, (4) each Assignee will rely upon the accuracy and completeness of such information and documents, (5) CAI, 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 information, or any other information that a Recipient deems necessary, (6) Applicant waives and releases any claims against Recipients and any information-providers arising from any act or omission relating to the requesting, receiving or release of information, and (7) each Owner/Officer represents that he or she is authorized to sign this form on behalf of Merchant.
Feel Free to Contact Us Anytime. • 212.972.2233 •
Qualify@ClaremontAdvance.com
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