FUNDING APPLICATION

Sales Rep. ID: ____________

[email protected]
6000 E. Evans Avenue, Suite 1-020, Denver, CO 80222
: 866-590-9138 (Toll Free)
: 720-307-4001
: 720-307-4002
Submit by Email

www.crestpointcapital.com

Print Form

Please fill in the spaces below, sign and mail or fax us the application. By doing so, you are giving Crestpoint Capital Inc. or its nominees, as well as its agents and affiliates, permission to review your
business and personal credit history in order to provide you with formal funding approval. All information supplied is confidential and shall be used solely for the purpose of determinining eligibility.
Business Legal Name:

Business DBA Name:

______________________________________ ______________________________________
Address:

Suite / Floor:

City:

State:

Zip:

______________________________________ ______________________________________ ______________________________________

Fax:

Mobile:

Tax ID #:

______________________________________ ______________________________________
______________________________________ ______________________________________

Legal Entity: Corp

E-mail:

Website:

Business Start Date (month / year):

Length of Ownership:

______________________________________ ______________________________________
Landlord / Mortgage Company:

Rent / Mortgage Payment:

Lease Expiration:

______________________________________ ______________________________________

______________________________________

Landlord Contact Name:

Landlord Contact Fax:

Landlord Contact Phone:

______________________________________ ______________________________________
T
R
A
D
E

R Company Name:
E
F ______________________________________
E
R Company Name:
E ______________________________________
N
C Company Name:
E
S ______________________________________

PRINCIPAL / OWNER DETAILS

Principal (1) Name:

______________________________________

Mr

______________________________________

Contact:

Telephone:

Contact:

Telephone:

Contact:

Telephone:

______________________________________ ______________________________________
______________________________________ ______________________________________
______________________________________
______________________________________
______________________________________
Mrs

Address:

Title:

% Ownership:

______________________________________

______________________________________

City:

State:

______________________________________ ______________________________________
Phone:

Fax:

Mobile:

Social Security #:

______________________________________ ______________________________________
E-mail:

______________________________________

SIGNATURE:

DATE:

______________________________________ ______________________________________

Mr

Principal (2) Name:

Mrs

______________________________________

Title:

% Ownership:

______________________________________

______________________________________

Address:

City:

______________________________________
State:

______________________________________ ______________________________________
Phone:

Fax:

Mobile:

______________________________________ ______________________________________

E-mail:

Zip:

______________________________________ ______________________________________

Zip:

______________________________________ ______________________________________
Social Security #:

______________________________________

SIGNATURE:

______________________________________ ______________________________________
FUNDING DETAILS

DATE:

______________________________________

Desired Advance Amount:

Minimum Advance Amount:

Average Ticket Size:

______________________________________

______________________________________

______________________________________

Average Monthly Visa/MasterCard Sales:

Average Monthly Total Sales:

______________________________________ ______________________________________
Proposed Use of Funds:

Current Processing Company:

______________________________________ ______________________________________
Bank Name:

Account Number:

Routing Number:

______________________________________ ______________________________________

______________________________________

Merchant Account Number:

AMEX Account Number:

Discover Account Number:

______________________________________

______________________________________ ______________________________________

Has applicant ever been in bankruptcy?:

YES
YES

NO

Are any suits/judgements/liens pending against the applicant:

NO
Balance:

Have you used a cash advance plan before?:

YES
YES

NO
NO