Loan Application Submission

Application for Financing

Please fill this form out in its entirety.

Broker Name (If applicable)

Business Information

Legal/Corporate Name* DBA Physical Business Address* City* State* Zip* Phone Number* Fax Number Federal Tax ID Date Business Started Length of Ownership

Owner Information

Corporate Officer/Owner Name* Title* Home Address* City* State* Zip Code* Own Rent Date of Birth* SSN* Home Phone Cell Phone*

Partner Information

N/A Partner Name Title Home Address City State Zip Code Own Rent Date of Birth SSN Home Phone Cell Phone

Thank you for submitting your application. Capital Growth Management will be in touch with you shortly.

Business Property Information

Lease or Own Business Property?* Lease Own N/A

Current on Lease/Mortgage? Yes No N/A

Term of Lease (if applicable)

Monthly Lease/Mortgage Payment

Contact Name and/or Account #

Phone Number

Business Trade References (if available)

1

Business Name

Contact, Account # or Fax

Phone Number

2

Business Name

Contact, Account # or Fax

Phone Number

3

Business Name

Contact, Account # or Fax

Phone Number

4

Business Name

Contact, Account # or Fax

Phone Number

Financial Information

Sales Information

Previous Year Gross Sales Gross Sales YTD Merchant Monthly Average

Loan Information

Requested Financing Amount* USE OF FUNDS: working capital / expansion*

Debt Information

Payroll Taxes Current?* Yes No

Have you or affiliates ever filed for bankruptcy?* Yes No

IF Yes current status

Any judgments,suits, or liens pending against company?

Current Loans and or Advances? If so list*

Loan Balances (if applicable)

Supporting Documents

Signed Application*

2014 Tax Return*

2015 Tax Return*

P and L*

Balance Sheet*

1003 (If Real Estate Loan is Requested)*

By signing and faxing or e-mailing us your Finance Application, you certify that (i) you are authorized to apply on behalf of the company whose full legal name appears above under the Company Information portion of the Finance Application for a business loan, advance or credit from us and or assignees and (ii) all information you provide within the Loan Application and other supporting documents is true and complete and that you will notify us of material changes to such information. You understand and agree that we and our agents and assignees are authorized to contact third parties to make inquiries in evaluating your Finance Application (including requesting business and personal credit bureau reports from credit reporting agencies and other sources) or for any update, renewal, extension of credit or other lawful purpose. Upon your request, we will advise you if we obtained a credit report and will give you the credit bureau’s name and address. You understand and agree that we may provide credit and other information from the Finance Application and on the signing individual(s) and the company with third parties who may use the information for any lawful purpose, including for the purpose of offering credit and/or other products and services to the signing individual(s) and/or the company. Applicant(s) irrevocably covenants, promises, and agrees, to indemnify Omega Funding and to hold Omega Funding their successors, heirs, officers, directors, shareholders, agents, representations and employees assigns (collectively, the "Indemnitees") harmless from and against any and all losses, claims, expenses, suits, damages, costs, demands, liabilities, joint or several, of whatever kind or nature resulting from or caused by the actions of Applicant(s) including without limitation in each case attorneys’ fees, costs, and expenses actually incurred in defending against or enforcing any such losses, claims, expenses, suits, damages, or liabilities except under the terms and conditions of this application. You understand and accept Application does not guarantee funding.

Submitted By*

Thank You

Submitted By

Please fill out & sign these forms prior to filling out the online application!

Application for Financing 1003 (For Real Estate Loans Only)