form

    BUSINESS INFORMATION

    Legal/Corporate Name:

    DBA:

    Physical Address:

    City:

    State:

    Zip:

    Telephone #:

    Fax #:

    Federal Tax ID:

    Date Business Started:

    Length of Ownership:

    Website:

    Type of Entity (select one):
    Sole ProprietorshipPartnershipCorporationLLCOther

    Email Address (required):

    Type of Business (select one):
    RetailMO/TOWholesaleRestaurantSupermarketOther

    Product/Service Sold:

    Amount Requested:

    Intended Use of Funds:



    MERCHANT/OWNER INFORMATION

    Corporate Officer/Owner Name:

    Title:

    Ownership %:

    Home Address:

    City:

    State:

    Zip:

    SSN:

    Date of Birth

    Home #:

    Cell #:



    PARTNER INFORMATION

    Partner Name:

    Title:

    Ownership %:

    Home Address:

    City:

    State:

    Zip:

    SSN:

    Date of Birth

    Home #:

    Cell #:



    BUSINESS PROPERTY INFORMATION

    Business Landlord or Business Mortgage Bank:

    Contact Name and/or Account #:

    Phone #:



    BUSINESS TRADE REFERENCES

    (Please list at least 3 trade suppliers. Please attach any additional references on a separate page.)

    Business Name:

    Contact Name and/or Account #:

    Phone #:

    Business Name:

    Contact Name and/or Account #:

    Phone #:

    Business Name:

    Contact Name and/or Account #:

    Phone #:

    Business Name:

    Contact Name and/or Account #:

    Phone #:



    AGENT USE ONLY

    Processing Company:

    Number of Terminals:

    Terminal Type:

    Requested Advance Amount:

    Requested Daily Withholding:

    Monthly Volume:

    Prior/Current Cash Advance Company (if applicable):

    Balance:



    Applicant authorizes Harbinger Capital Group, its assigns, agents, banks or financial institutions to obtain a consumer credit report from a credit bureau or a credit agency and to investigate the references given on any other statement or data obtained from applicant.