Application

Current Information*

	YES	NO
Does this company have any Federal, State, City, Local or Payroll taxes past due?
Are there any existing or pending judgments against this company?
Are there any existing, pending or threatened litigation against this company:
Does this company have any outstanding Bank Loans, Lines of Credit, Cash Advances, and/or other forms of financing against the business?

◉ Past Due amount for Federal, State, City, Local or Payroll taxes:
◉ Brief description of existing or pending judgment(s) against this company:
◉ Brief description of existing, pending or threatened litigation against this company:
◉ Total current balance for outstanding Bank Loans, Lines of Credit, Cash Advances, and/or other forms of financing against the business:

THREE LARGEST CUSTOMERS (IN TERMS OF FACTORING VOLUME) THAT YOU WANT TO FACTOR:*

	Company Name:	Trailing 3 months Sales $:	Average amount of time to collect (days):	Street address:	Suite:	City:	State:	Zip:	Phone:	Requested Credit Limit $:
1
2
3

THREE LARGEST CUSTOMERS (IN TERMS OF FACTORING VOLUME) THAT YOU WANT TO FACTOR:
CUSTOMER 1
Company Name*
Phone*
Street Address*
Suite
City*
State:*
Zip:*
Requested Credit Limit $:*
Average # of Days to Collect: *
Days
Trailing 3 Months Sales $:*
CUSTOMER 2
Company Name
Phone
Street Address
Suite
City
State:
Zip:
Requested Credit Limit $:
Average # of Days to Collect:
Days
Trailing 3 Months Sales $:
CUSTOMER 3
Company Name
Phone
Street Address
Suite
City
State:
Zip:
Requested Credit Limit $:
Average # of Days to Collect:
Days
Trailing 3 Months Sales $:
Current Accounts Receivable Aging Report Upload:

CLICK HERE TO UPLOAD Open Accounts Receivable Aging Report (Current)

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How did you hear about us?*
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