Please take a moment to provide us with the following information to facilitate the funding process Annual Sales Revenue Amount SeekingPlease select... Under $20,000 $20,000 - $30,000 $30,000 - $40,000 $40,000 - $50,000 $50,000 - $75,000 $75,000 - $100,000 $100,000 - $150,000 $150,000 or more Use of FundsPlease select... Inventory Equipment Pay Down Debt Expansion Payroll Working Capital Receivables Delayed Other Industry / Business TypePlease select... Accounting/Finance Advertising/Public Relations Aerospace/Aviation Arts/Entertainment/Publishing Automotive Banking/Mortgage Beauty Bridal Business Service CLEANING Clerical/Administrative Construction Consumer Goods Dental Education Electronics Energy/Utilities Engineering Entertainment Farming FLOWER Food & Beverage Retail Food & Beverage Wholesale Furniture Healthcare Heating / Hvac / AC Hospitality/Travel Installation/Maintenance Insurance Internet IT / Technology Jewelry Law Enforcement/Security Legal Liquor Lodging Manufacture Manufacturing/Operations Marketing Medical Pet Pharmaceutical/Biotech Professionals Real Estate Restaurant/Food Service Retail Sales Service Technology Telecommunications Transportation Wholesaler Other Products Sold / Services Offered by your business Business Info Business Phone Date Established Business Name Business Address CountryPlease select... Canada United States City ProvincePlease select... AB BC MB NB NL NS NT NU ON PE QC SK YT StatePlease select... AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Postal Code Zip Code Monthly Rent / Mortgage Payment(if applicable) Company Website Federal Tax ID (EIN) Please enter your business' 9-digit Federal Tax ID number in the specified format. x Business Identification Number (BIN) Please enter your business' 9-digit Federal Tax ID number in the specified format. x Personal Info First Name Last Name Lead Source - Hidden Lead Source Sales Partner Lead Sales Partner OWNER / USER ID Prefill OWNER / USER ID Lead OWNER / USER ID Default OWNER / USER ID Sales Partner Email Marketing Profile ID DLogic StatusPlease select... Requested Success! Failed Merchant Does Not Have Online Access Merchant does not want to Complete DL MTD Completed via another Method DLogic StagePlease select... Active Inactive Active - Date Range Error @ Decision Logic Dlogic Code