Manhattan Bridge Capital

* These fields must be filled

*Contact Name:
*Title:
*Legal Name of Business:
*Trade Name (DBA):
*Street Address:
*City:
*State:
*Zip code:
*Phone Number:
*Fax Number:
Cell Number:
*Email Address:
*Legal Form Of Business:
Corporation Partnership LLC Sole Proprietor Other
State Established:
Years in Business:
Federal Tax ID#:
D.U.N.S Number:
Describe Business:

Bank Name:
Bank's Street Address:
City:
State:
Zip code:
Bank's Phone Number:
Checking Acct #:
Savings Acct #:
Loan #:

Accountant's Name:
Accountant's Street Address:
City:
State:
Zip code:
Accountant's Phone Number:

Attorney's Name:
Attorney's Street Address:
City:
State:
Zip code:
Attorney's Phone Number:

Landlord's Name:
Landlord's Street Address:
City:
State:
Zip code:
Landlord's Phone Number:

*Total Receivable Outstanding: $
(0-30 days): $
(31-60): $
(61-90): $
(Over 90 days): $
Average Monthly Sales: $
Amount financing requested: $
Average Number of Invoices per Month:
Average Invoice Value: $
Total Number of Customers:
Average Number of Customers Sold to per Month:
Average Number of Days to Collect:
Write-off Percentage:
Receivables Generated from: Goods Sale of Services Other
Terms of Sale:
Purpose of Loan:

Has the Company ever factored or pledged its receivables as collateral? Yes No
If yes, explain:
Are there any loans, private or commercial, now outstanding? Yes No
If yes, explain:
Are any extended terms granted in respect of receivables? Yes No
If yes, explain:
Are any Federal or State taxes, including Payroll Taxes, delinquent? Yes No
If yes, explain:
Are there any Judgements or Liens now pending or in effect against the company? Yes No
If yes, explain:
Has the Company or any of its Principals ever filed for Bankruptcy protection? Yes No
If yes, explain:
Has any Owner, Officer, or Principal Manager of the Company ever been convicted of a felony? Yes No
If yes, explain:
Do you use a payroll service such as ADP, Paychex or your bank? Yes No
If yes, explain:
Does the company do business from more than one place? Yes No
If yes, explain:
Has the Company ever operated under a different name? Yes No
If yes, explain:
Do you have any ownership in other companies? Yes No
If yes, explain:

Owner/Officer:
Street Address:
City:
State:
Zip code:
Phone Number:
Social Security Number:
Driver's License:
Date of Birth:
Position:
Ownership Percentage:

Company Name:
Contact:
Street Address:
City:
State:
Zip code:
Phone Number:
Fax Number:
Account Number:
Monthly Volume: $

Please send the following documents to the following address:
(These are required for the application to move forward)

192 Lexington Ave.
5th Floor
New York, NY 10016

Detailed Accounts Receivable Aging
Master Customer List with names, address and telephone numbers
Recent Financial Statements
Sample invoices, & supporting documt’n (POD, Order, etc.)
Detailed Accounts Payable Aging
Copy of I.D. (drivers license or passport)
Copy of Articles of Incorporation, LLC Certificate of Membership or Partnership Agreement

The above items have been sent on:

The information supplied in this Confidential Financing Application, Company Profile form, and all forms and documents submitted (collectively the “Application”) to Manhattan Bridge Capital Inc., its subsidiaries or its Assignee (collectively “Funder”) in connection herewith is true and correct to the best of my/our knowledge and belief. I/We hereby authorize Funder to investigate my/our financial responsibility and credit worthiness and will provide financial statements, tax returns, or other materials or information as requested by Funder and to verify any information provided from any source Funder may choose. I/We grant Funder the right to procure any and all credit or other investigative reports to any party to this application. I/We grant Funder the right to release any of the information contained herein or any results from any investigation of the information contained herein to any third party that may become part of any financing transaction between applicants and Funder or to whom Funder may refer this applicant to for funding. I/We further grant to any source from which Funder has requested information about applicant(s), the authorization to release such information to Funder. Applicant acknowledges that Funder will rely on the information provided herein to make its credit decision regarding Applicant. This Application has been completed and signed under penalty of perjury. A photocopy, including a fax copy, of this authorization may be accepted as an original.

*Name: *Date: