Type of Entity (Select One):
Merchant Type:
Officer / Owner Information
Please Complete Additional Application(s) for Additional Owner(s)
By submitting this application, the person(s) listed above agree to the following:
Applicant hereby authorizes Genesis Funding and their affiliates, assigns, agents, banks or financial institutions to obtain an
investigative or consumer report from a credit bureau or credit agency and to investigate the business information given on any other
statement or data obtained from applicant. Applicant, your name below represents your signature. Signing below further represents
that all the information contained herein is complete and accurate. This authorization will be valid for two (2) years from the date below.
