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First Name
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Last Name
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Business Email Address
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Business Legal Name
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Business Phone Number
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Doing Business As (DBA) Name
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Business Type
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Business Type
Business Start Date
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Federal Tax ID # (EIN)
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Business Address
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Business City
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Business State
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Select Business State
Business Zip Code
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Mobile Phone Number
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Website URL
Industry
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Owner Name
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Date Of Birth
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Social Security Number
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Ownership %
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Are there multiple owners?
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Yes
No
Second Owner Name
Second Owner Email
Second Owner Ownership %
Home Address
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Home City
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Home State
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Select Home State
Home Zip Code
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Do you own multiple businesses
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Yes
No
Are you working with an LCF rep?
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Yes
No
If yes, who is your rep?
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Reliant Funding (“Reliant”) is a division of The LCF Group, Inc. The Merchant and Owner(s)/Officer(s) identified above (individually, and "Applicant") each represents, acknowledges and agrees that (1) All the information and documents provided to Reliant ("Representative") including credit card processor statements are true, accurate and complete, (2) Applicant will immediately notify Representative of any change in such information or financial condition, (3) Applicant authorizes Representative to disclose all information and documents that Representative may obtain including credit reports to the 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) Representative and each Assignee will rely upon the accuracy and completeness of such information and documents (5) Representative, Assignees, and each of their representatives, successors, assigns and designees (collectively, "Recipients") are authorized to request and receive and investigative reports, credit reports, statements from creditors or financial institutions, verification information, or any other information that a Recipient deems necessary, (6) Applicant waives and releases and claims against Recipients and any other 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.
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