Factoring Application

*Registered Entity Name:

Trade Name:

*Email Address:

*Address:

*City:

*State:

*Zip:

—Please choose an option—AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

*Business Phone:

*Business Fax:

County:

*Type of Entity

CorporationLLCPartnershipProprietorship

or Other:

*Date Formed:

*State of Incorporation:

*Federal Tax ID:

—Please choose an option—AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

*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?

YesNo

If Yes, with whom?

When?

Are You Currently Factoring?

YesNo

If Yes, with whom?

Contract End Date?

*Owner Name:

*Home Address:

*Social Security Num:

*Date of Birth:

Home Phone:

Cell Phone:

*Title:

*% of Owner Ship:

*Title

*Company

*Address

*Length of Service

*Brief Job Description

*Title

*Company

*Address

*Length of Service

*Brief Job Description

Have you ever declared bankruptcy?

YesNo

Are there any unsatisfied judgments or tax liens against you?

YesNo

Are there now, or have you ever been a party to any litigation?

YesNo

Have you granted any lien or security interest in any of your assets to anyone within the last five (5) years?

YesNo

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?

YesNo

Owner Name:

Home Address:

Social Security Num:

Date of Birth:

Home Phone:

Cell Phone:

Title:

% of Owner Ship:

Title

Company

Address

Length of Service

Brief Job Description

Title

Company

Address

Length of Service

Brief Job Description

Have you ever declared bankruptcy?

YesNo

Are there any unsatisfied judgments or tax liens against you?

YesNo

Are there now, or have you ever been a party to any litigation?

YesNo

Have you granted any lien or security intrest in any of your assets to anyone within the last five (5) years?

YesNo

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?

YesNo

I HEREBY SUBSCRIBE AND 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.