Factoring Application

Fill out the application below for your invoice factoring financing solutions that will help take your business to the next level..

*required fields

General Information

*Registered Entity Name:
Trade Name: *Email Address:
*Address: *City: *State: *Zip:
*Business Phone: *Business Fax: County:
*Type of Entity
or Other:
*Date Formed:   *State of Incorporation:   *Federal Tax ID:
   

How Did You Hear About Accounts Receivable Funding?
Accounts Receivable Information
*Total A/R Balance: 1-30 days: 31-45: 46-60: 60+:
*Annual Sales 2008: Avg. Monthly Sales 2009: *Monthly Amount to be Factored:
Num. Active Customers: Largest Customer: % of Business: Average Inv Size:
Have You Ever Factored Before? Yes | No
  If Yes, with whom? When?
Are You Currently Factoring? Yes | No
  If Yes, with whom? Contract End Date?

Ownership Information (Must Account for 100%)

Owner Number One
*Owner Name: *Home Address:
*Social Security Num: *Date of Birth: Home Phone: Cell Phone:
*Title: *% of Owner Ship:
Owner Number One Employment History (Most Recent Employment First)
*Title *Company *Address *Length of Service
*Brief Job Description

*Title *Company *Address *Length of Service
*Brief Job Description

Have you ever declared bankruptcy? Yes No
Are there any unsatisfied judgments or tax liens against you? Yes No
Are there now, or have you ever been a party to any litigation? Yes No
Have you granted any lien or security intrest in any of your assets to anyone within the last five (5) years? Yes No
Have any of the principals (IE: directors, officers, shareholders, partners, members) been involved with a business similar to that of applicant within the last five (5) years? Yes No

Owner Number Two
Owner Name: Home Address:
Social Security Num: Date of Birth: Home Phone: Cell Phone:
Title: % of Owner Ship:
Owner Number Two Employment History (Most Recent Employment First)
Title Company Address Length of Service
Brief Job Description

Title Company Address Length of Service
Brief Job Description
Have you ever declared bankruptcy? Yes No
Are there any unsatisfied judgments or tax liens against you? Yes No
Are there now, or have you ever been a party to any litigation? Yes No
Have you granted any lien or security intrest in any of your assets to anyone within the last five (5) years? Yes No
Have any of the principals (IE: directors, officers, shareholders, partners, members) been involved with a business similar to that of applicant within the last five (5) years? Yes No

I HEREBY AFFIRM, THAT ALL THE INFORMATION PROVIDED IS TRUE AND ACCURATE. Accounts Receivable IS AUTHORIZED TO VERIFY THE ACCURACY OF THE STATEMENTS AND INFORMATION PROVIDED AND TO CONDUCT CREDIT AND CRIMINAL INVESTIGATION, INCLUDING WITHOUT LIMITATION, OBTAINING ONE OR MORE CREDIT REPORTS FROM CREDIT BUREAUS.ANY ADVERSE MATERIAL CHANGE TO THE FINANCIAL INFORMATION PREVIOUSLY SUPPLIED, MUST BE REPORTED WITHIN FIFTEEN (15) DAYS.