Contact & Basic Business Info

Please complete your personal and business contact information below.

Business Details

Tell us about your company’s structure and financial profile.

BUSINESS NAME

DBA

Doing Business As

State of Incorporation

Industry

Business Start Date

YYYY

Federal Tax ID

Enter your 9-digit EIN number (no dashes)

Business Email

Website

http://

Business Phone

(###)

###

####

Ownership %

Business Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Number of Employees

Do you process credit cards?

CURRENT CREDIT SCORE

Monthly Revenue

Estimate average gross revenue from the past 3 months

GROSS ANNUAL SALES

Current Business Debt

Bank Name

For Current Business Debt

REQUESTED AMOUNT

Brief description of usage of funds.

Contact Information

information about the business owner or majority partner

Name

First Name

Last Name

Date of Birth

YYYY

TITLE

SSN

Enter your 9-digit number (no dashes)

Mobile Phone

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PARTNER INFORMATION

Partner Name

First Name

Last Name

Partner Date of Birth

YYYY

PARTNER TITLE

Partner SSN

Partner Business Email

Partner Mobile Phone

(###)

###

####

Partner Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Partner Ownership %

Partner FICO Score

Representative Name

Authorization Statement

I authorize Wellspring Capital to obtain my credit and background information, including business and personal credit reports, for the purpose of evaluating my application. I affirm that the information provided is accurate and complete. I consent to be contacted via phone, email, or text.

Applicant Signature

Typing your name acts as a legally binding digital signature.

Partner Signature

Typing your name acts as a legally binding digital signature.