APPLICATION

Business Address:

TAX ID:

FIRST/LAST NAME

SS#

DOB:

Any Existing Loans ? If Yes Please list each Lender and the current Balance. If None then Type None

By signing below, each of the above listed business and business owner/officer (individually and collectively, “you”) authorize Capital Headquarters and each of its representatives, successors, assigns and designees (“Recipients”) that may be involved with or aquire commercial loans having daily,weekly or Monthly repayment features or purchases of future receivables including, Line of Credits, Merchant Cash Advance transactions, including without limitation the application therefor (collectively, “Transactions”) to obtain consumer or personal, business and investigative 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 CH 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 the release, by any creditor or financial institution, of any information relating to any of you, to CH and to each of the Recipients, on its own behalf.

Your Signature