Credit Application for Alternative Risk Transfer Loan

Einstein Capital, LLC 
302A W 12 TH ST., #127
New York, NY 10014

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Part I. Applicant & Business Information

Personal Information
Authorized Individual Title
Authorized Individual First Name	Authorized Individual Last Name
Street Address	Suite/Apt/Other (optional)
City	State
	Armed Forces AmericasAlaskaAlabamaArmed Forces PacificArkansasAmerican SamoaArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaFederated States of MicronesiaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMarshall IslandsMichiganMinnesotaMissouriNorthern Mariana IslandsMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoPalauRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanNorthwest TerritoriesYukon Territory
Zip Code	Who Referred You?
Email Address	Phone Number
Business Information
Entity Type
Choose OneCorporationLimited Liability Company (LLC)PartnershipSole Proprietorship
Business Legal Name	If your business uses a DBA (Doing Business As), please provide here
Federal Employer Identification Number (EIN)	Business Established Date (mm/yyyy)
Is Your Business's Physical Address the Same as Your Personal Address? (if "no" please provide the business address)  Yes   No
Street Address	Suite/Apt/Other (optional)
City	State
	Armed Forces AmericasAlaskaAlabamaArmed Forces PacificArkansasAmerican SamoaArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaFederated States of MicronesiaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMarshall IslandsMichiganMinnesotaMissouriNorthern Mariana IslandsMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoPalauRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanNorthwest TerritoriesYukon Territory
Zip Code	Business Website
Business Email Address (if different than personal email address)	Business Phone Number (if different than personal phone number)
Number of Employees (Enter "0" if you're the only employee)	Business Category
	Choose OneAgriculture, Forestry, Fishing, HuntingMining, Quarrying, Oil & Gas ExtractionUtilitiesConstructionManufacturing: Apparel, Food, Textile, TobaccoManufacturing: Chemicals, Minerals, Oil, Paper, WoodManufacturing: Electronics, Furniture, Machinery, Metal, Transportation, Misc.Wholesale TradeRetail: Automotive, Clothing, Food, Gas, Health, Home GoodsRetail: Books, Hobbies, Music, Sports, General, Nonstore RetailTranspiration: Air, Ground, Pipeline, Rail, Water, Tourism, SupportTranspiration: Postal, Courier, StorageInformation Technology ServicesFinance and InsuranceReal Estate and Rental and LeasingProfessional, Scientific, Tech ServicesManagement of Companies and EnterprisesAdmin/Support/Waste Mgmt/Remed SvcsEducational ServicesHealth CareProfessional AthleteOther
Please Provide a Detailed Description of Your Business

 

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Part II. Loan Requested

Amount Requested (please specify the amount of loan principal requested)
$

 

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Part III. Operating Company Financial Information

A. Financial Statements. Please attach copies of the Applicant's (Operating Entity) tax returns for the past 2 years (1120 or equivalent). If submitting a 1040, please also include YTD P&L and Balance Sheet.

 

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Part IV. Important Information

The information contained in this application and the information provided on all accompanying financial statements and schedules is provided for the purpose of obtaining credit for the Applicant. Applicant understands it is applying for Alternative Risk Premium Funding through Einstein Capital and/or affiliates. All loans subject to approval.  Applicant warrants that the above information represented in this application, and financial statements, profit and loss statements, statements as to ownership, and other statements given to Einstein Capital and/or affiliates are true and correct. In making this application, Applicant understands and acknowledges Einstein Capital will be relying on the information provided in determining creditworthiness and to grant such credit. Applicant represents by this application that the Company is a going concern, that the business will be continued, and that Company understands that the proceeds of the loan will be used in connection with Alternative Risk Transfer Funding payable directly to the insurer.  This Application is part of the Loan Documents. Loan is subject to terms and conditions contained within the Loan Documents. Loan approval and terms subject to final determination by Einstein Capital Underwriters. Loans may not be approved for use in all jurisdictions. It is recommended that you consult legal advice regarding Alternative Risk Transfer Funding. Nothing in this Application is intended to induce reliance by the Applicant nor should Applicant rely on loan amount disbursement until a final determination letter is issued.   This Statement is true and correct in every detail and accurately represents the financial condition of the Applicant on the date given below. Einstein Capital and/or affiliates are authorized to make all inquiries it deems necessary to verify the accuracy of the information contained herein and to determine the creditworthiness of the Applicant. Applicant will promptly notify Einstein Capital of any subsequent changes which would affect the accuracy of this Statement. Applicant is aware that any knowing or willful false statements regarding the value of the above property for purposes of influencing the actions of a creditor can be a violation of U.S. Federal law,18 U.S.C. Sec. 1014, and may result in a fine  or imprisonment or both. I have the authority to, and wish to obtain a financial loan through Einstein Capital; the information in this application is true and correct to the best of my knowledge; no false representations, warranties, nor was false information was provided; I agree to the terms and conditions outlined herein; and I agree to the understandings, representations and warranties above:
Please Initial
By signing below, the undersigned agrees to all the terms and conditions contained in this Application.
Business Name	Authorized Individual Name
You acknowledge, by submitting this application you agree to the terms and conditions herein, if you do not agree please do not submit this application. Thank you.