FUNDING PRE-QUALIFICATION FORM

CONTACT INFORMATION
Business Legal Name: Business DBA (if applicable):

Business Phone: Mobile Phone:

Business Fax: Other Phone:

Website: Email:

Physical Address: City: State: Zip:

Mailing Address: City: State: Zip:

BUSINESS INFORMATION
Legal Entity (select one): □ Corporation □ LLC □ Partnership □ LP □ LLP □ Sole Proprietorship
Business Start Date: Federal Tax ID: Home Based Business? Open Judgements/Liens? Open Bankruptcies? State of Inc/LLC:

□ YES □ NO □ YES □ NO □ YES □ NO

Business Rent/Mortgage Information: Mthly Rent/Lease/Mtg Payment: Remaining Term for Rent/Lease: Payment Current?
□ Rented/Leased □ Mortgaged □ YES □ NO
Landlord/Mortgage Company Contact: Phone Number:

FUNDING INFORMATION
Amount Requested: When Are Funds Needed: Desired Use of Funding Proceeds:
□ ASAP □ 30 Days □ 60+ Days
Gross Annual Sales: Gross Monthly Sales: Monthly Credit Card Volume: Current Cash Advance? Cash Advance/Loan Balance:
□ YES □ NO
Current Credit Card Processing Company: Account Number:

OWNER/PRINCIPAL INFORMTION
First Name: MI: Last Name: Title: % Ownership:

Home Address: City: State: Zip:

Home Phone: Mobile Phone: Date of Birth: SS#:

CO-OWNER/PRINCIPAL INFORMATION
First Name: MI: Last Name: Title: % Ownership:

Home Address: City: State: Zip:

Home Phone: Mobile Phone: Date of Birth: SS#:

AUTHORIZATION
By signing below, each of the above listed business and business owner/officer (individually and collectively, “you”) authorize GoldPoint
Funding and each of its representatives, successors, assigns and designees (“Recipients”) 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 therefore (collectively, “Transactions”) to obtain consumer or personal, business and
investigative reports and other information about you, including credit card processor statements and bank statements, from one or
more consumer reporting agencies, such as TransUnion, Experian and Equifax, and from other credit bureaus, banks, creditors and
other third parties. You also authorize GoldPoint Funding to transmit this application form, along with any of the foregoing information
obtained in connection with this application, to any or all the Recipients for the foregoing purposes. You also consent to the release, by
any creditor or financial institution, of any information relating to any of you, to GoldPoint Funding and to each of the Recipients, on its
own behalf.
Owner Signature: Co-Owner Signature:

Printed Name: Printed Name:

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 Email signed Pre-Qualification Form to: [email protected]

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