Collier Wright, Jr. La Grange KY, 40031
PH: 502.602.0019
Cell: 502.702.9707

Main Street Business Loans Application

Any Box Surrounded In Red Upon Submission Is Required



Business Legal Name


DBA Name


Business Address

Suite/Floor

City


State or Province

Zip


US County


Main Business Phone


Fax


Business Website


Merchant Email Address

Federal State Tax # or PAN Card#

Legal Structure: (Click One)

Merchant Type: (Click One)

Business Location Type: (Click One)

Date Business Started
*

Use Of Loan Proceeds?


Declared Bankruptcy In The Last 7 Years?

Do You Have Any Tax Liens?

Have Any Judgments?

Is Your Business Seasonal?
Do You Rent or Own Your Home?

Number of Years Lived There?


Are You A US Citizen?

Products / Services Sold

Business Landlord/Mortgage & References


TRADE REFERENCE 1:
Name

Phone

BANK REFERENCE :
Name

Phone


LANDLORD/MORTGAGE COMPANY:
Company Name


Do You Rent or Own Your Business Location?
RENT/MORTGAGE PAYMENT:
Monthly Payment (number only)


Owner/Principal Information

This business has Owner(s) With 51% or More Ownership


Name Title Address City


State or Province

Zip Phone

Email


% of Ownership (Must Be 51% Owner)


Date of Birth
*

SSN#
Annual Income


Driver's License # and State of Issue


Funding Information


Does Your Business Accept Credit Cards?
Gross Annual Revenues: Loan Amount Requested

Have You Used A Cash Advance Plan Before?
Average Bank Balance:

By signing below, each of the above listed business and business owner/officer (individually and collectively, "you") authorize Main Street Business Loans dba United Cash Solutions and each of its representatives, successors, assigns and designees ("Recipients") 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 therefore (collectively, "Transactions") to obtain consumer or personal, business and investigative reports and other information about you, including credit card processor statements and bank statements, from one or more consumer reporting agencies, such as TransUnion, Experian and Equifax, and from other credit bureaus, banks, creditors and other third parties. You also authorize Main Street Business Loans dba United Cash Solutions to transmit this application form, along with any of the foregoing information obtained in connection with this application, to any or all of the Recipients for the foregoing purposes. You also consent to the release, by any creditor or financial institution, of any information relating to any of you, to Main Street Business Loans dba United Cash Solutions and to each of the Recipients, on its own behalf. You expressly consent to receiving emails and text messages, as well as any live or prerecorded telephone calls, including to your mobile phone, regarding loan options. You can opt-out from receiving further communications from Main Street Business Loans dba United Cash Solutions by emailing [email protected]


Owner