Full Loan Application

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To submit a simplified loan application click here.

BUSINESS INFORMATION

- required fields.

LEGAL BUSINESS NAME:
DBA NAME:
PHYSICAL ADDRESS:
CITY:
STATE:
ZIP:
BUSINESS PHONE:
BUSINESS FAX:
TYPE OF ENTITY:
FEDERAL TAX ID (9 digits):
BUSINESS START DATE:
# OF LOCATIONS:
BUSINESS PROPERTY TYPE:
MONTHLY RENT/MORTGAGE:
ANNUAL GROSS SALES:
AMOUNT REQUESTED:
USE OF FUNDS:
EXISTING ADVANCE?
IF SO, WITH WHO:
OUTSTANDING BALANCE:

OWNERSHIP INFORMATION

PRINCIPAL OWNER NAME:
OWNERSHIP %:
SSN#:
D.O.B.:
HOME ADDRESS:
CITY:
STATE:
ZIP:
HOME PHONE:
CELL:
E-MAIL ADDRESS:


PARTNER NAME:
OWNERSHIP %:
SSN#:
D.O.B.:
HOME ADDRESS:
CITY:
STATE:
ZIP:
HOME PHONE:
CELL:
E-MAIL ADDRESS:




The Merchant and Owner(s)/Officer(s) identified above (individually, an “Applicant”) each represents, acknowledges and agrees that (1) all information and documents provided to Versa Business Systems including credit card processor statements are true, accurate and complete, (2) Applicant will immediately notify Versa Business Systems of any change in such information or financial condition, (3) Applicant authorizes Versa Business Systems to disclose all information and documents that Versa Business Systems may obtain including credit reports to other persons or entities (collectively, "Assignees") 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"), and each Assignee is authorized to use such information and documents, and share such information and documents with other Assignees, in connection with potential Transactions, (4) Versa Business Systems and each Assignee will rely upon the accuracy and completeness of such information and documents, (5) Versa Business Systems, Assignees, and each of their representatives, successors, assigns and designees (collectively, “Recipients”) are authorized to request and receive any investigative reports, credit reports, statements from creditors or financial institutions, verification of information, or any other information that a Recipient deems necessary, (6) Applicant waives and releases any claims against Recipients and any information-providers arising from any act or omission relating to the requesting, receiving or release of information, and (7) each Owner/Officer represents that he or she is authorized to sign this form on behalf of Merchant. A copy of this authorization may be accepted as an original. A copy of this authorization may be accepted as an original. The term “Versa Business Systems” shall mean any funding source looking to offer, make available, or provide to the Merchant access to loans or merchant cash advances based on such Merchant’s future receivables or sales and/or structured with a periodic repayment feature.