Business Information Please fill in the spaces below and submit. By doing so, you are giving Diversified, 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.

  • Business Info
  • Owner Info
  • Funding Info
  • Important Questions
  • E-Sign

Business Info

Business Legal Name

Business DBA Name

Type of Business Entity?

Type of Industry

Physical Address / Street Address

City

State

Zip Code

Is Mailing Address Different?

Is Mailing Address Different?

Business Phone Number

Business Fax Number

Mobile Phone Number

Business Email Address

Current Website

Type of Business / Products Sold

Federal Tax ID #:

Business Start Date

Property Ownership?

Type Of Building

Owner Info

Owners First Name

Owners Last Name

Percent Of Ownership

Home Address / Street Address

City

State

Zip Code

Home Phone

Home Fax

Mobile Phone Number

Email Address

Date Of Birth

Social Security Number

Driver License Number

Driver License State of Issuance

Funding Info

Average Monthly Deposits

Desired Advance Amount

Purpose Of Advance

Current Advance

Has your company ever defaulted on an advance?

Have any of your companies in the past defaulted on an advance?

Important Questions

Important Questions

Has your business ever Filed Bankruptcy?

Has the owner ever Filed Bankruptcy?

Does your Business have any Tax Liens?

Does your Business have any Outstanding Loans or Credit Lines?

Average Credit Rating for your Business?

E-Sign

By signing below, each of the above listed business and business owner/officer (individually and collectively, “you”) authorize Diversified Financial Solution and each of its representatives, successors, assigns and designees (“Recipients”) that may be involved with or acquire commercial loans having daily repayment features or purchases of future receivables including Merchant Cash Advance transactions, including without limitation the application therefor (collectively, “Transactions”) to obtain consumer or personal, business and investigative reports and other information about you, including credit card processor statements and bank statements, from one or more consumer reporting agencies, such as TransUnion, Experian and Equifax, and from other credit bureaus, banks, creditors and other third parties. You also authorize Diversified Financial Solution to transmit this application form, along with any of the foregoing information obtained in connection with this application, to any or all of the Recipients for the foregoing purposes. You also consent to the release, by any creditor or financial institution, of any information relating to any of you, to Diversified Financial Solution and to each of the Recipients, on its own behalf. Signature Here

Owners First Name

Owner Last Name