Kirtz Investments

Name(Required)

First Last

Date of Birth(Required)

On average what has your business grossed in monthly revenue for the past 6 months?(Required)

What do you think your credit score is?(Required)

How much capital are you looking for?(Required)

Industry

Email(Required)

Phone Number(Required)

EIN Number

SSN

Business Name

Business Address

Street Address Address Line 2 City State ZIP Code

Personal Address

Street Address Address Line 2 City State ZIP Code

Years in Business

File

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CAPTCHA

By signing below, the Merchant and its owners/ principal: (1) certify that all information and documents submitted in connection with this application is true, correct and complete; and (2) authorize KIRTZ INVESTMENTS INC. and each of its representatives, successors, assigns and designee(“Recipients”) to receive credit reports and any other information regarding the Merchant and its owners and principals from third parties, to verify any information provided on the Application.

Signature(Required)

By signing above, the Merchant and its owners/ principal: (1) certify that all information and documents submitted in connection with this application is true, correct and complete; and (2) authorize KIRTZ INVESTMENTS INC. and each of its representatives, successors, assigns and designee(“Recipients”) to receive credit reports and any other information regarding the Merchant and its owners and principals from third parties, to verify any information provided on the Application.