Business Funding Application Legal Business Name * What is the legal name of the business looking for funding? Business DBA Name (if applicable) Does the business have any other trade name or d/b/a name? Business Legal Structure What is the legal structure of the business looking for funding? Sole Proprietorship Corporation Partnership Not-For-Profit Corporation Limited Liability Company Limited Partnership Don't Know... State of Incorporation * Where was the business incorporated? Business Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Location Type What kind of location does the business operate from? Factory / Warehouse Retail / Store Front Office / Studio Laboratory / Research Facility Home Business Phone * What is the main phone number of the business looking for funding? Country (###) ### #### Business Website Does the business have a website? http:// Date Business Started * When did the business looking for funding begin? MM DD YYYY Business Tax ID * What is the Federal Tax ID (EIN) of the business looking for funding? Gross Annual Revenue * What is the gross annual revenue of the business? Funding Requested * How much funding does the business need? Use of Proceeds * What does the business need funding for? Business Working Capital Purchase Equipment Remodel Develop a Product Business Training Participate in a Trade Show Business Expansion Open a New Location Buy a Business Partner's Interest Pay Business Taxes Payroll Buy Inventory Hire a Temporary Staff Other Industry Type What industry does the business operate in? Auto Repair Beauty/Salon Contractor Doctor/Dentist/Veterinarian Healthcare/Childcare E-Commerce Gas Station/Convenience Store Grocery/Super Market HVAC Manufacturing Oil Production Services Pharmacy Real Estate Agent Restaurant/Bar Retail Technology Transportation Travel/Entertainment Wholesale Other Unknown Principle Owner Principle Owner Name * First Name Last Name Principle Owner's Equity Percentage Enter Principle Ownership Percentage Principle Owner Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Principle Owner Phone * Country (###) ### #### Principle Owner Email * Principle Owner Date of Birth * MM DD YYYY Principle Owner SSN * Principle Owner Drivers License Trade References Trade Reference 1 Company Reference 1 Contact First Name Last Name Reference 1 Phone Country (###) ### #### Trade Reference 2 Company Reference 2 Contact First Name Last Name Reference 2 Phone Country (###) ### #### Trade Reference 3 Company Reference 3 Contact First Name Last Name Reference 3 Phone Country (###) ### #### Real Estate Expenses Landlord or Mortgage Holder Contact Person First Name Last Name Contact Number (###) ### #### Monthly Rent or Mortgage Payment Thank you. A representative from Moxy Capital will be in touch!
