Field Marked (*) are Mandatory

BUSINESS INFORMATION
Legal Name of Company:
Registered Trade Name (D.B.A.):
Corporate Headquarters:
Street Address:
City:
State:
Zipcode:
* Business Telephone
Business Fax:
Primary Contact regarding this Application:
Web Address:
* E-mail Address:
Years in Business:
State Business Established :
Is Business :
Describe Business:
Does business have more than one office?

If yes, how many
Any subsidiaries, licensees, franchisees or affiliates?
Has company ever filed for bankruptcy?
Are there any judgments pending by or against the company?
Is there any pending or threatened litigation against the company?
Federal Tax ID:
Any Federal or State taxes past due?
State Incorporation Number (State ID # ):
PRINCIPALS OF BUSINESS
Principle 1
Name:
Title:
% Owned
Social Security #:
Drivers License :
Phone:
Home Address:
City:
State:
Zipcode:
Principle 2
Name:
Title:
% Owned
Social Security #:
Drivers License :
Phone:
Home Address:
City:
State:
Zipcode:
BUSINESS BANKING
Financial Institution:
Contact:
Phone:
Fax:
Are Accounts Receivable and/or inventory pledged as collateral?
ACCOUNTS RECEIVABLE INFORMATION
Amount of open Receivables (Total Outstanding):
$
  Aging of Receivables ($ Amount)
0-30 days:
$
31-60 days:
$
61-90 days:
$
Over 90 days:
$
Is business currently or has it previously factored its receivables?
If currently factoring, with whom?
Average monthly amount company wants to factor:
$
LARGEST ACCOUNTS YOU EXPECT TO FACTOR
List1
Company Name:
Monthly Sales:
$
Desired amount of credit :
Average amount of time to collect (days):
Phone:
Address:
List2
Company Name:
Monthly Sales:
$
Desired amount of credit :
Average amount of time to collect (days):
Phone:
Address:
List3
Company Name:
Monthly Sales:
$
Desired amount of credit :
Average amount of time to collect (days):
Phone:
Address:
List4
Company Name:
Monthly Sales:
$
Desired amount of credit :
Average amount of time to collect (days):
Phone:
Address:
Where did you hear about us?