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:
$7,500-$10,000/month $10,001-$25,000/month $25,001-$50,000/month $50,001-$100,000/month $100,001-$250,000/month $250,001-$500,000/month $500,001-$750,000/month $750,001-$1,000,000/month $1,000,001-$5,000,000/month $5,000,001+ /month
Please select the value
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:
Corporation Partnership LLC Individual Others
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Business Type:
Ad Agencies Aluminum / Alloy Mfg. Business to Business Computer Industry Consulting Firms Distributors High Tech. Field Light Manufacturing Manufacturing Other Service Providers Staffing Firm Steel Industry Trucking/Transportation Wholesale IT Services Network Services Software Computer Related Oil Well Related Chemical Firms Printing Firms Label Printing Companies Steel Manufacturing Janitorial Service Oriented Graphic Design Web Design TV Production Marketing Law Firms Textile Manufacturing Other Manufacturing Sign Companies Publishing Vendors to Large Retail Outlets Wal-Mart Vendors
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Describe Business:
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Does business have more than one office?:
Yes
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If yes, how many?:
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Any subsidiaries, licensees, franchisees or affiliates?:
Yes
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Has company ever filed for bankruptcy?:
Yes
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Are there any judgments pending by or against the company?:
Yes
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Is there any pending or threatened litigation against the company?:
Yes
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Federal Tax ID: (*)
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Any Federal or State taxes past due
Yes
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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?:
Yes
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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?
Yes
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If currently factoring, with whom? :
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Average monthly amount company wants to factor $:
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Captcha
Refresh
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