Business Funding

Application

Company Name *

Doing Business As *

Entity Type *

Federal Tax Id (XX-XXXXXXX) *

Industry *

Business Start Date *

Annual Revenue *

Monthly Revenue

Amount of Capitol Requested *

Purpose of Capital *

Current Advance And Balances

Business Phone *

Business Address *

Business Email *

City *

State *

Zip *

Owner First Name *

Owner Two First Name

Owner Last Name *

Owner Two Last Name

Percent Ownership *

Percent Ownership

Home Address *

Home Address

City *

City

State *

State

Zip Code *

Zip Code

Email *

Email

Date of Birth *

Date of Birth

Social Security #

Social Security #

Comments

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 ATX Funding Source, LLC ("MOBYCAP") including credit card processor statements are true, accurate and complete, (2) Applicant will immediately notify ATX Funding Source, LLC of any change in such information or financial condition, (3) Applicant authorizes Libertas Funding LLC to disclose all information and documents that ATX Funding Source, LLC 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) each Assignee will rely upon the accuracy and completeness of such information and documents, (5) , ATX Funding Source, LLC 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.