Working Capital Pre-Qualification — Granite Capital Access Ventures

Contact Information

Business legal name*

Business DBA (if applicable)

Business phone*

Mobile phone

Business fax

Other phone

Website

Email*

Physical address*

City*

State*

Zip*

Mailing address

City

State

Zip

Business Information

Legal entity*

Business start date*

Federal Tax ID*

State of Inc/LLC*

Industry type (SIC code)

Home-based business?*

YesNo

Open judgments / liens?*

YesNo

Open bankruptcies?*

YesNo

Business description*

Business rent / mortgage

Rented / LeasedMortgaged

Monthly rent / lease / mortgage payment

Remaining term

Payment current?

YesNo

Landlord / mortgage company contact

Phone number

Funding Information

Amount requested*

When are funds needed?*

Desired use of funding proceeds*

Gross annual sales*

Gross monthly sales*

Monthly credit card volume

Cash advance / loan balance

Current cash advance?*

YesNo

Current credit card processing company

Account number

Owner / Principal Information

First name*

MI

Last name*

Title*

% Ownership*

Home address*

City*

State*

Zip*

Home phone

Mobile phone*

Date of birth*

SSN*

Co-Owner / Principal Information (optional)

First name

MI

Last name

Title

% Ownership

Home address

City

State

Zip

Home phone

Mobile phone

Date of birth

SSN

Supporting Documents (optional)

Upload a business plan, pitch deck, or related documentation. Allowed formats: PDF, Word, Excel, PNG, JPG. Maximum 50 MB.

Choose a fileNo file selected

Authorization

By submitting this form, the undersigned certifies that the information provided is true and accurate, and authorizes Granite Capital Access Ventures and its lending partners to obtain credit reports and verify any information contained herein.

I certify and authorize the above.

Signature*

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A drawn signature is required to submit.

Printed name*

Date*