Customer ApplicationCoined Inc. Customer Application Business Legal Name: DBA (Doing Business As): * Legal Entity * LCC Sole Prop Corp State of Incorporation: * EIN Number (Tax ID): * Industry Type: * Business Phone Number: * (###) ### #### Business Email: * Full Business Address: * Is it Rented or Owned: * Rented Owned Rent / Mortgage Payment:* * Start Date * MM DD YYYY Gross Annual Sales (Previous Tax Return): * Owner Information Full Name * Phone Number * (###) ### #### Date Of Birth * MM DD YYYY Home Address * Email * Ownership Percentage * Social Security Number * Second Owner Information (If Applicable) Full Name: Phone Number (###) ### #### Date Of Birth MM DD YYYY Home Address Email Social Security Number Ownership Percentage FUNDING AMOUNT How much is needed? * What will the funds be used for? * Do you have any current cash advances? * Yes No How many cash advances? (If Applicable) DOCUMENTS Here you can upload your most 4 recent business banking statements (Required to Determine Loan Amount) DISCLOSURE and SIGNATURE By signing below, each of the above Businesses and Business Owners/Officers (Individually and collectively, “you”) authorize Coined Inc. 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 MCA transactions, including without limitation the application therefor (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 Coined Inc. 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 release, by any creditor or financial institution, of any information relating to you, to Coined Inc. and to each of the recipients, on its own behalf Acknowledgement I have read and agree to the terms above Print Full Name * Signed Date * MM DD YYYY Thank you!
