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Syndicate Lenders Application

Business Information

Gazarotti Group LLC /Syndicate Lenders Application

Type of Entity *

Legal Business Name *

DBA *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Federal Tax ID *

Business Start Date *

MM / DD / YYYY

Phone *

### - ### - ####

Fax

### - ### - ####

Email

Web Site

Contact Name *

Industry Type *

Owner Information

Owner *

First Last

Ownership % *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Mobile *

### - ### - ####

Date of Birth *

MM / DD / YYYY

Social Security # *

Owner #2 Information (If Applicable)

Partner

First Last

Ownership %

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Mobile

### - ### - ####

Social Security #

Date of Birth

MM / DD / YYYY

Revenue

Monthly Credit Card Sales *

Monthly Gross Sales *

Gross Annual Sales *

Amount Requested *

Use of Funds *

Existing Advance (If none type 0 in the fields below)

Balance *

Company *

Daily Payment / Holdback % *

Property Information

Type of Property *

Own

Lease

Home Based

Land Lord / Mortgage Co. *

Rent / Mortgage Amount *

Contact *

Contact Phone # *

### - ### - ####

Questions

Any Pending Claims, Judgments, Tax Liens, or Bankruptcies? *

No

Yes, Please Explain Below

Authorization

Applicant authorizes Syndicate Lenders its assigns, agents, banks or financial institutions to obtain an investigative or consumer report from a credit bureau or a credit agency and to investigate the references given on any other statement or data obtained from applicant.

Authorization

Signature #1 *

Clear

Date Time *

MM / DD / YYYY

Signature #2

Clear

Date Time

MM / DD / YYYY

Last 4 Months of Bank Statements

Please only attach the statements in pdf form

Bank Statement #1

Bank Statement #2

Bank Statement #3

Bank Statement #4