Business Advance Request Form

Business Advance Request Form

Use this form to request a short-term business advance. Complete all fields, attach required documentation, and sign the agreement at the end. Submission constitutes a request and an acknowledgement that any advance, if approved, will be evidenced by the terms set forth in the Agreement section below.

Applicant Information

Advance Request Details

Requested Disbursement Date:   Desired Repayment Term (months):

Financial Snapshot & Collateral

Agreement — Recitals and Terms

WHEREAS, Applicant Name: represents that it is a business formed under the laws of and seeks an advance for the purposes described above;

WHEREAS, Lender Name: is willing to consider an advance to Applicant on the terms set forth herein and subject to credit verification and documentation.

NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, the parties agree as follows:

Scope of Work

The Advance shall be used for the business purposes and project activities described below. Applicant shall apply the funds only to the stated purposes and shall provide evidence of use upon Lender request.

Payment Terms

Advance Amount:   Fee / Interest Rate:

Payments shall be due in accordance with the repayment schedule selected above. Applicant authorizes automatic collection from the business bank account for scheduled payments where applicable. Late payment shall incur a late fee equal to: % of the overdue amount after days.

If Applicant fails to make timely payments or otherwise breaches any material covenant, Lender may declare the entire unpaid balance immediately due and payable and exercise any security interest or remedies permitted by law and under any security agreement executed in connection with this Advance.

Term and Termination

Term Start Date:   Maturity / End Date:

Either party may terminate this agreement for material breach if the breaching party fails to cure within days after written notice. Termination does not relieve Applicant of obligations to repay any outstanding balance accrued prior to termination.

Confidentiality

Each party shall hold confidential all non-public information received from the other party that is marked confidential or would reasonably be understood to be confidential given the nature of the information and the circumstances of disclosure. Confidential information shall not include information that is or becomes generally available to the public other than through a breach of this Agreement or that was rightfully received from a third party without restriction.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the state of without regard to conflict of law principles.

Entire Agreement

This Agreement, together with any schedules, security agreements and disclosures executed in connection herewith, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior negotiations, understandings and agreements between the parties. Any amendment must be in writing and signed by both parties.

Certifications and Authorizations

By checking the box below, Applicant certifies that the information provided in this form is true, complete and accurate to the best of Applicant's knowledge. Applicant authorizes Lender to verify any information provided and to obtain business and personal credit reports where permitted by law.

Applicant Representative Name:   Title:

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