Broker Information
Name:
Company:
Title:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
We require that you be in direct communication with the note holder/client. We do not entertain broker/daisy chains.
Company Information
Legal Name of Company:
*
Street Address 1:
*
Street Address 2:
*
City:
*
State:
*
Zip Code:*
*
Contact Information
Name:
*
Title:
*
Phone:
*
Fax:
*
Email:
*
Business Details
Type of Business Entity:
*
Corporation
Legal Partnership
LLC
Sole Proprietorship
Other (specify)
If other, please put it here.
How long has your company been in business:
*
Services or products provided:
*
Does your company or your principles have any lawsuits?:
*
Yes
No
Does your company or your principles owe any back taxes?:
*
Yes
No
Does your company or its principles have any judgments?:
*
Yes
No
Does your company or your principles have any current loans?:
*
Yes
No
If yes, indicate loan amount ($):
Does your company have any liens on receivables?:
*
Yes
No
Transaction Details
Average Monthly Sales Volume:
*
Number of Active Customers:
*
Average time between billing and collecting:
*
Amount needed to fill current order:
*
Suppliers
Supplier 1 Name:
*
Address:
*
City:
*
State:
*
Zip:
*
Phone:
*
Items Needed:
*
Cost:
*
Supplier 2 Name:
*
Address:
*
City:
*
State:
*
Zip:
*
Phone:
*
Items Needed:
*
Cost:
*
Supplier 3 Name:
*
Address:
*
City:
*
State:
*
Zip:
*
Phone:
*
Items Needed:
*
Cost:
*
Customer
Name:
*
Address:
*
City:
*
State:
*
Zip:
*
Phone:
*
Describe Order:
*
Amount to be billed:
*
Comments:
*
Enter the code as it is shown:
*
Submit
Should be Empty: