Full Application
Basic information
Contact Person First Name: (*)
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Contact Person Last Name: (*)
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Contact Email: (*)
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Legal Name of Company:
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Registered Trade Name (D.B.A.):
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Total Invoices Outstanding:
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Amount Needed: (*)
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Corporate headquaters
Your Website:
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City:
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State:
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Zipcode: (*)
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Business Telephone: (*)
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Business Fax:
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Years in Business:
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State Business Established:
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Is Business:
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Business Type:
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Describe Business:
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Does business have more than one office?:
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If yes, how many?:
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Any subsidiaries, licensees, franchisees or affiliates?:
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Has company ever filed for bankruptcy?:
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Are there any judgments pending by or against the company?:
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Is there any pending or threatened litigation against the company?:
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Federal Tax ID: (*)
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Any Federal or State taxes past due
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State Incorporation Number (State ID #):
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Principals of business
Principal 1
Name:
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Title:
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Social Security #:
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Drivers License:
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Phone:
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Home Address:
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City:
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State:
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Zipcode:
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Principal 2
Name:
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Title:
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Social Security #:
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Drivers License:
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Phone:
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Home Address:
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City:
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State:
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Zipcode:
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Business Banking
Financial Institution:
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Contact:
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Phone:
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Fax:
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Are Accounts Receivable and/or inventory pledged as collateral?:
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Accounts Receivable Information
Amount of open Receivables (Total Outstanding) $:
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Aging of Receivables ($ Amount)
0-30 days:
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31-60 days:
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61-90 days:
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Over 90 days:
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Is business currently or has it previously factored its receivables?
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If currently factoring, with whom? :
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Average monthly amount company wants to factor $:
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