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:
		---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:
		---AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

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?	YesNo
	If Yes, with whom?	When?

Are You Currently Factoring?	YesNo
	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?	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 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?	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.

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