Please type-in yur information, and print the application by fax or e-mail.

2500 W. Orangethorpe Ave. Suite 113 Fullerton, CA 92833 Telephone: 1-877-799-9221 Fax: 1-866-584-0836 www.workingcapitalgenie.com

Working Capital Qualification Questionnaire

1.How much cash do you need? $ 2.What is the main usage of the funding? 3.What is your average monthly card sales? $ 4.Current on your business lease? Yes No No years month No Total monthly sales? $ By when:

5. Do you have at least one year left on your business lease? Yes 6.Current on your mortgage? Yes No

If behind, how many months?

7.Do you have an open bankruptcy (must be discharged 1 year) or Tax Lien? Yes 8.On a scale of one to ten, how would you rate your credit? (1-10) 9.Do you have an existing cash advance? Yes Original amount $ No If Yes, paid off date:

Approx. balance $

Hold back rate

Legal Company Name: Email address: Type of business entity: Business Address: Years in business: yrs Fed. Tax ID: Corporation LLC

DBA name:

Sole Prop City:

Partnership State: Zip:

Type of Business: Cell # Fax # Landlord Phone #: Average Monthly Credit Card Volume:$ Type of Terminal : Internet sale/phone order percentage of total sale: Current balance: $ % of Ownership: Co-owners Name: %

Phone Number: Business # Landlord Name: Average Monthly Gross Income:$ Current Merchant Processor Name: Contact at processing company: Average balance on business account: $ Owners Name:

Home Address:

Home Address:

# of years lived at this add.? Home Phone #: Social Security #: Date of Birth: Driver's License #: Annual Income: $

years

# of years lived at this add.? Home Phone #: Social Security #: Date of Birth: Driver's License # Annual Income: $ References

years

NAME 1. 2. 3.

RELATIONSHIP

PHONE #

I hereby authorize you to whom this application is made, or your guests, to investigate or verify my own credit worthiness and will provide financial statements as you deem necessary. I certify that all information on this application is true and accurate. I/ we will not be held responsible for any liability and damages to the companies related with CDS that might result from this application. Any false information may be a cause for denial of the loan. I have read and understood the above statement.

Signature Signature

Date Date

We offer additional service to increase your cash flow, if interested, please put a check mark below.
**Merchant Service Fee Saving: Working Capital Genie is a proud supporter of MAUI (Merchant Against Unfair Interchange) Association, with a mission to rally support to pass the law with Congress to properly regulate the credit card processing industry. There is a high probability (9 out of 10 business owners) are being overcharged with hidden fees on merchant statements. We can implement savings between 6% - 20% average on fees. This will be a free-analysis offered by fortune 500 talent whom we hired, to stop the unfair overcharges and hidden fees on merchant statements. Lowering your business expense is a great way to increase your cash flow and profit margin. If you are interested in this risk-free service, please check here.