Working Capital Application

1 Company Information 2 Personal Information 3 Additional Information Legal Company Name* Company Address* Street AddressAddress Line 2City StateZIP Code Business Phone* Alternative Phone Fax Number Email Address* Federal Tax ID* Business Start Date* MM DD YYYY Business Type/Industry* Type of Business* Corporation Proprietorship Partnership Non-Profit Principal #1* FirstLast % Ownership* Please enter a value less than or equal to 100. Social Security #* Principal #1 Address* Street AddressAddress Line 2City StateZIP Code Annual Income Additional Owners? Principal #2 FirstLast % Ownership Please enter a value less than or equal to 100. Social Security # Principal #2 Address Street AddressAddress Line 2City StateZIP Code Annual Income Intended Use of Funds Requested Amount* Annual Business Revenue* Average Monthly Bank Balance* Monthly Credit Card Volume If applicable Additional Collateral If applicable, please provide a general list of unsecured collateral (equipment, vehicles, real estate etc) and estimated market values. Terms and Conditions The Merchant and Owner(s)/Officer(s) identified above (individually, an "Applicant") each represents, acknowledges and agrees that (1) all information and documents provided to Capital Alliance Corporation ("CAC") including bank and credit card processing statements are true, accurate and complete, (2) Applicant will immediately notify CAC of any change in such information or financial condition, (3) Applicant authorizes CAC to disclose all information and documents that CAC may obtain including credit reports to other persons or entities (collectively, "Assignees") that may be involved with or acquire commercial loans having daily repayment features or purchases of future receivables including Merchant Cash Advance transactions, including without limitation the application therefore (collectively, "Transactions") and each Assignee is authorized to use such information and documents, and share such information and documents with other Assignees, in connection with potential Transactions, (4) each Assignee will rely upon the accuracy and completeness of such information and documents, (5) CAC, Assignees, and each of their representatives, successors, assigns and designees (collectively, "Recipients") are authorized to request and receive any investigative reports, credit reports, statements from creditors or financial institutions, verification of information, or any other information that a Recipient deems necessary, (6) Applicant waives and releases any claims against Recipients and any information-providers arising from any act or omission relating to the requesting, receiving or release of information, and (7) each Owner/Officer represents that he or she is authorized to sign this form on behalf of Merchant. * Accept Terms and Conditions

Working Capital Application

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