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Borrower Information

Name of the Borrower *

Email Address *

Phone Number *

Business Name (if applicable)

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Business Information

Name of business *

Business DBA *

Business address *

City

State

ZIP / Postal Code

Date business started *

Website address *

Legal entity type *

Federal tax ID *

Monthly Business Revenue *

USD

Product/service offered

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Crypto Asset Information

Type of Crypto Asset

Cryptocurrency Name

Value of Crypto to Be Used as Collateral

USD

Purpose of the Loan

Estimated Loan Amount Needed

Loan Details

Requested Loan Amount *

USD

Value of Collateral *

USD

Preferred Loan Term

Repayment Frequency

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