Funders You Can Trust! Reliant Funding is a division of The LCF Group, Inc.

First Name

Last Name

Email Address

Business Phone Number

Business Legal Name

Business DBA Name

Legal Entity Proprietor

Business Start Date

Federal Tax ID # (EIN)

Business Address

Business City

Business State

Business Zip Code

Mobile Number

Website URL

Type of Business

Owner Name

Ownership %

Multiple Owners

Yes No

Second Owner Name

Second Ownership %

Second Ownership Email

Date of Birth

Social Security Number

Home Address

Home City

Home State

Home Zip Code

Do you own multiple businesses?

Yes No

Are you working with a Reliant Funding rep?

Yes No

If yes, who is your rep?

The Merchant and Owner(s)/Officer(s) identified above (individually, and "Applicant") each represents, acknowledges and agrees that (1) all the information and documents provided to The LCF Group ("Representative") including credit card processor statements are true, accurate and complete, (2) Applicant will immediately notify Representative of any change in such information or financial condition, (3) Applicant authorizes Representative to disclose all information and documents that Representative may obtain including credit reports to the other persons or entities (collectively, "Assignees") 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 therefor (collectively, "Transactions"), and each Assignee is authorized to use such information and documents, and share such information and documents with other Assignees, in connection with potential Transactions, (4) Representative and each Assignee will rely upon the accuracy and completeness of such information and documents, (5) Representative, Assignees, and each of their representatives, successors, assigns and designees (collectively, "Recipients") are authorized to request and receive and investigative reports, credit reports, statements from creditors or financial institutions, verification information, or any other information that a Recipient deems necessary, (6) Applicant waives and releases and claims against Recipients and any other information-providers arising from any act or omission relating to the requesting, receiving, or release of information, and (7) each Owner/Officer represents that he or she is authorized to sign this form on behalf of Merchant. A copy of this authorization may be accepted as an original.

I agree to the Terms of Service and Privacy Policy.

I swear or affirm that I am the party described above and that all statments in this application, including those pertaining to my identity are true.

Signature

Signed Date