Application Page Application Form Business Details Business Description Financial Information Owner Information Business Details Legal Business Name DBA Name Business Street Address City & State Business Zip Code Business Phone Business Description Owned Business Since Business Open Date Ownership Own Lease Monthly Rent/Mortgage Payment Lease Start Date Business Description Number of Employees 0-10 11-25 26-40 50-65 65+ Number of Locations 1 2 3 4 5+ Business Structure Corp LLC Sole Prop LLP LP Partnership Other Types of Electronic Payments Accepted Average Month sales Volume From Electronic Payments Estimated Monthly Total Sales Requested Financing Amount Are you Currently using a Billing Company? Federal Tax ID Number Is your Business for Sale? Do you have any Federal or State Tax Liens? Do you have any Outstanding Financing? Have you filed for Bankruptcy? Intended Use of Proceeds? Owner Information Principal Owner Name Date of Birth Principal Owner Home Address Principal Owner Social Security Number Principal Owner Email Address Ownership Percentage Principal Owner Home Phone Principal Cell Phone Past 4 Months Bank Statements By Checking here the applicant Agrees & Electronically Authorizes to the following; The Business Applicant and each person signing this Application (“Signer”) certifies that all information provided by the Business Applicant and Signer is true and complete and authorizes VALLEXA, LLC and any of its affiliates (collectively “VALLEXA”) to: 1) obtain credit and/or employment information about the Business Applicant and Signer; 2) obtain credit reports and make any inquiries regarding the Business Applicant and VALLEXA considers appropriate in connection with this Application or reviews of the Business Applicant's account from time to time; and 3) disclose account information as permitted by law. The Business Applicant and Signer acknowledge that additional information may be required in order to render a decision on this Application. By Checking here the applicant Agrees & Electronically Authorizes to the following; SIGNER ACKNOWLEDGES THAT VALLEXA MAY RELY ON THE STATEMENTS AND INFORMATION SET FORTH IN THIS APPLICATION AND THAT SUCH STATEMENTS AND INFORMATION MAY BE INCORPORATED BY REFERENCE IN ANY AGREEMENT ANY OF THE UNDERSIGNED MAY ENTER INTO WITH VALLEXA. EACH OF THE UNDERSIGNED HEREBY AGREES TO NOTIFY VALLEXA PROMPTLY OF ANY CHANGE IN ANY SUCH STATEMENT OR INFORMATION. SIGNER HAS READ AND UNDERSTANDS THE TERMS OF THIS APPLICATION, INCLUDING ANY ADDENDUM, AND REPRESENTS AND WARRANTS THAT THE INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT. By Checking here the applicant Agrees & Electronically Authorizes to the following; If applying for a loan, please note that the federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant's income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning VALLEXA is the Federal Trade Commission, Equal Credit Opportunity, Washington, DC 20580.