Form

Tell us everything you know about the deal:*

Date of Submission:*

This section only needs to be completed if a broker is submitting the receivable application on behalf of their client.

Company:

Full Name

First Name Last Name

Title:

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

- Area Code Phone Number

Fax:

- Area Code Phone Number

E-mail

Are you in direct contact with the client?:

We require you to be in direct communication with the client. We do not entertain broker/daisy chains.

Client Full Name*

First Name Last Name

Client Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Client Phone Number*

- Area Code Phone Number

Client Fax:*

- Area Code Phone Number

Client E-mail*

DBA:*

Federal Tax ID#:*

Type of Business:*

If other, please explain:

Date Business Started:*

State of Incorporation:*

Describe Type of Business:*

Please be as accurate as possible, as the rest of the below questions will help our investors determine how much of advancement towards your receivables that they can offer!

What is your average monthly volume?:*

How much of your average monthly billing do you wish to factor?:*

Monthly Billing Administration:*

Does the applicant or its principal(s) have any judgements or liens filed against them?:*

If yes, please explain:

Does the applicant or its principal(s) have any lawsuits against them?:*

If yes, please explain:

Are your payroll, federal and state income taxes current?:*

If no, please explain:

How much bad debt did you write off last year?:*

Is there any security interest granted that covers accounts receivable?:*

If yes, please explain:

Do you have any outstanding loans?:*

If yes, please explain:

Name of Financial Institution:*

Address of Financial Institution:*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Balance owed $:*

Contact Name:*

First Name Last Name

Phone:*

- Area Code Phone Number

Ext:*

Fax:*

- Area Code Phone Number

First Bank Name:*

Phone:*

- Area Code Phone Number

Contact Name:*

First Name Last Name

Account Number:*

Second Bank Name:*

Phone Number*

- Area Code Phone Number

Contact Name*

First Name Last Name

Account Number:*

If the company seeking Factoring for their Account Receivables, has more than one 1 corporate officer, then we will need the detailed information regarding the other corporate officers as well! If there is more than 3 corporate officers, please contact us to let us know how many corporate officers you have, so we can email you a customized form to fill out. Thank you for your cooperation!

First Officer Name:*

First Name Last Name

Title:*

Home Address:*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Social Security Number:*

Date of Birth:*

Ownership %:*

Second Officer Name:

First Name Last Name

Title:

Home Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Social Security Number:

Date of Birth:

Ownership %:

Third Officer Name:

First Name Last Name

Title:

Home Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Social Security Number:

Date of Birth:

Ownership %:

Enter the code as it is shown:*

Cover Letter

Broker Information

Contact Information of Client

Business Information

Account Information

Bank Accounts

Corporate Officers