New Client Application Form
Company Legal Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Organization or Incorporation
-
Month
-
Day
Year
Date
State of Organization or Incorporation
Name of any Affiliate, Subsidiary, Holding or Parent Company
Applicant Name & Title
First Name
Last Name
Title
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Principal(s)
President, Sole Proprietor, or Senior Partner
Secretary, Shareholder or Other Partner
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Tax Information
Federal EIN
Number of Full-Time Employees
Number of Part-Time Employees
How often do you file 941 Payroll Taxes?
Weekly
Monthly
Quarterly
Annually
Do you have any past due Federal or State taxes?
Please Select
Yes
No
Unknown
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Creditors & Debt
Balance on All Outstanding Loans
$0
$1-$100,000
$100,001-500,000
$500,001-1,000,000
$1,000,000 or Greater
Are you Presently Leasing Office Space?
Please Select
Yes
No
If Yes, What is the Term of the Lease?
Does the Company Own Real Estate?
Please Select
Yes
No
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Customer and Receivable Information
What is the Intended Use of Funds Generated from Factoring?
Dollar Amount of Currently Open Receivables
Are Your Receivables Pledged as Collateral?
Please Select
Yes
No
List All Customers You Initially Intend to Factor
Rows
Legal Name
Address
City, State, Zip
Average Monthly Sales Volume
Sales Terms
Customer
Customer
Customer
Customer
Customer
Customer
Customer
Customer
Customer
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General Information
Any Pending Litigation Against Company, Sole Proprietor(s) or Partners?
Please Select
Yes
No
Any Judgments Outstanding?
Please Select
Yes
No
Unknown
Any Federal or State Tax Liens?
Please Select
Yes
No
Has any Owner or Officer Been Involved in a Bankruptcy?
Please Select
Yes
No
If you answered "Yes" to any of the above, please provide a brief explanation:
Signature
Submit
Submit
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