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.