Contact - Parx Capital Group

Business Information

Legal Business Name

DBA (If different)

Legal Entity

Corp LLC Sole Prop LP Other

Date Business Established (MM/DD/YYYY)

Business Classification

Retail Restaurant Services Manufacturer/Wholesaler Internet MailOrder/Telephone Order

Physical Address

Mailing Address

Business Phone

Business Fax

Mobile

E-Mail

Website

Tax ID Number or Business Number

Terminal/POS Make/Model

Property Ownership

Lease Own

Years in Control

Months in Control

Products Sold

Landlord / Mortgage Company Name

Landlord Contact Name

Landlord / Mortgage Company Phone

Rent / Mortgage Payment

Has the business or any principal ever filed for Bankruptcy Protection?

Yes No

Are there any pending, threatened, or recently filed claims, judgments or tax liens?

Yes No

Owner / Principal Information

Name

Title

% of Ownership

Home Address

Home Phone

Cell Phone

E-Mail

Date of Birth (MM/DD/YY)

Social Security

Drivers License #

Drivers License State

Co-Owner / Principal Information (Optional)

Name

Title

% of Ownership

Home Address

Home Phone

Cell Phone

E-Mail Address

Date of Birth (MM/DD/YY)

Social Security

Drivers License #

Drivers License State

Trade References

Company (Largest Vendors)	Contact Name	Contact Phone Number

By signing below, the Merchant and its Owners/Principals certify that all information and documentation submitted with this application is true, correct, and complete. The undersigned expressly authorize the Purchaser of Receivables to obtain and utilize consumer credit reports on any Owner/Principal, as well as any other relevant business or personal information from third-party sources, for purposes of verifying and reviewing this application. The financial products offered are structured as the true sale and purchase of future receivables and related commercial financing arrangements. These transactions are strictly for business purposes only and do not constitute consumer loans. Any funding is provided directly by the Purchaser at its sole and absolute discretion, subject to underwriting and execution of final agreements.

Owner/Principal Signature:

SIGN HERE

Type your name above

Date:

Print Name:

Please Answer the Following Questions

How many employees are on your business payroll and receive W-2 wages?

How many individuals does your business compensate as independent contractors by 1099?

How many businesses are compensated by your company as independent contractors by 1099?

Are you paid by the business as W-2 or 1099?

If paid by the business, what is your annual compensation?

Do you have any outstanding business debts? (yes/no)

Yes No

If yes to the above question, what is the total outstanding debt amount?

Do you own the property at your current business address? (yes/no)

Yes No

If yes to the above question, what is the current value of the property?

Have you ever been convicted of a criminal offense? (yes/no)

Yes No

If yes to the above, what was the offense?

What is your current personal net worth (total personal assets minus liabilities)?

What is the total value of all outstanding accounts receivable owed to the business that are under 90 days old as of the date of this application?

How many days does it typically take to collect your accounts receivable (15, 30, 45, or more)?

Get Funded.

Business Information

Owner / Principal Information

Co-Owner / Principal Information (Optional)

Company Information

Trade References

Please Answer the Following Questions