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Business Information
Owner Details
Capital Information
Step
1
of
14
- Business Information
7%
Legal Business Name
(Required)
DBA Name
Federal Tax ID
Industry
Time in Business
(Required)
Please Select One
Less than 1 Year
1 - 2 Years
2 years or more
Business Start Date
MM slash DD slash YYYY
Website (Old Field)
Business Phone
Website
Business Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
State of Incorporation
(Required)
Please Select One
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Structure
(Required)
Corporation
LLC
LLP
Partnership
Sole Proprietor
Seasonal Business
Yes
No
Property Information
Mortgage
Own
Rent
Monthly Property Payment
Average Gross Annual Revenue
(Required)
Please Select One
Less than $100k
$100k - $299k
$300k - $399k
$400k - $499k
$500k+
Gross Annual Sales
Is Credit Card Sales Part of Income?
Yes
No
Avg Monthly Credit Card Sales
Owner Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
SSN
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Email
(Required)
Phone
(Required)
Open Bankruptcies
Yes
No
Open Judgements/Liens
Yes
No
Bankruptcy Type
Ownership %
(Required)
Please enter a number from
1
to
100
.
Are there other owners?
Yes
No
Copy of Drivers License/State ID
Drop files here or
Select files
Accepted file types: pdf, jpg, jpeg, png, Max. file size: 10 MB.
Last 3 months Bank Statements
Drop files here or
Select files
Accepted file types: pdf, jpg, jpeg, png, Max. file size: 10 MB.
Amount Requested
(Required)
Use of Funds
(Required)
Do you currently have any working capital loans?
(Required)
Yes
No
Balance
Authorization Agreement
(Required)
I agree to the following authorization statement.
By signing below, the Business and Owner(s) identified above (individually, an “Applicant”) each represents, acknowledges, and agrees that all information and documents provided in connection with this application are true, accurate, and completeand Applicant will immediately notify Eliot Ventures LLC (“Denali”) of any change in the Business’ financial condition. Applicant understands and agrees that Denali and our agents, representatives, assignees and partners, which includes finance providers with whom Denali has, or may in the future enter into, brokerage relationships (“Recipients”), are authorized to contact third parties to make inquiries, including but not limited to (1) obtain consumer, business and investigative reports and other information about you, including credit pulls (hard or soft), from one or more consumer reporting agencies, such as TransUnion, Experian and Equifax; (2) obtain credit card processor statements and bank statements from banks, creditors and other third parties; (3) release any claims against Denali, Recipients and any information-providers arising from any act or omission relating to the requesting, receiving, or release of information;(4) ) contact Applicant via e-mail, call and/or text-message at the e-mail address and/or phone number provided above, or at any e-mail address and/or phone number reasonably identified as belonging to you, including wireless numbers (if applicable), even if listed on a Do-Not-Call registry, using an automated telephone dialing system or other similar system with respect to this application, future-related commercial-financing opportunities and/or other lawful telemarketing purposes. Each Owner of the Business represents that he or she is authorized to sign and submit this application on behalf of Business.
Owner Signature
(Required)
Printed Name
(Required)
Date
(Required)
MM slash DD slash YYYY
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