Business Credit Application for WideQ Financial
NAME OF THE COMPANY APPLYING FOR FINANCING:
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ADDRESS OF THE COMPANY APPLYING FOR FINANCING:
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ALL ASSUMED, FICTITIOUS, OR TRADE NAMES:
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DATE OF FORMATION:
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Month
-
Day
Year
Date
STATE OF FORMATION:
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FEDERAL I.D. NUMBER:
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EIN
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EMPLOYEES:
NUMBER PERMANENT OF EMPLOYEES:
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NUMBER TEMPORARY OF EMPLOYEES:
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NUMBER INDEPENDENT CONTRACTORS:
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AR & SALES INFORMATION:
CURRENT OPEN A/R:
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# OF INVOICES PER MONTH:
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LAST 30 DAY SALES:
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LAST YEAR SALES:
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TERMS OF SALE (Net 30, etc):
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PROJECTED NEXT 12 MONTHS SALES:
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BRIEF DESCRIPTION OF BUSINESS:
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GENERAL INFORMATION
Are receivables currently pledged as collateral?
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Yes
No
If yes, to whom?
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Has the Company ever financed it’s A/R before?
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Yes
No
If yes, with whom?
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Is the Company currently involved in any civil or criminal judicial, administrative, or arbitration proceeding or is any such action being threatened by anyone?
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Yes
No
Are there any unsatisfied judgments, liens, or levies against the Company, whether or not of record?
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Yes
No
Has the Company ever had a petition in bankruptcy filed by or against it, or is the Company considering filing bankruptcy or is an involuntary bankruptcy being threatened against it?
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Yes
No
Are any local, state, or federal taxes delinquent, or are there any liens related to such taxes filed or threatened to be filed, or is the Company presently under any installment agreements (oral or written) for the payment of such taxes?
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Yes
No
Does the Company purchase goods or services from any firm it also sells to?
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Yes
No
Does the Company have any Progress Billing prior to completion/delivery?
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Yes
No
Does the Company accept Customer Deposits?
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Yes
No
Does the Company Bill Now but Hold customer merchandise on your premises for shipment later?
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Yes
No
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OWNERSHIP & OFFICERS
For ALL individuals reflecting 100% of ownership, and management personnel.
TITLE:
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% OWNERSHIP:
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NAME:
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First Name
Last Name
PHONE NUMBER:
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Please enter a valid phone number.
Format: (000) 000-0000.
E-MAIL:
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example@example.com
HOME ADDRESS:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
This Home is:
*
Please Select
OWNED
RENTED
SS#:
DRIVER’S LICENSE #
DRIVER’S LICENSE STATE:
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
DRIVER’S LICENSE PHOTO (FRONT AND BACK)
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DATE OF BIRTH:
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Month
-
Day
Year
Date
HOW MANY YEARS AT FIRM:
*
*
MARRIED
UNMARRIED
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OWNERSHIP & OFFICERS #2
For ALL individuals reflecting 100% of ownership, and management personnel.
TITLE:
% OWNERSHIP:
NAME:
First Name
Last Name
PHONE NUMBER:
Please enter a valid phone number.
Format: (000) 000-0000.
E-MAIL:
example@example.com
HOME ADDRESS:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
This Home is:
Please Select
OWNED
RENTED
SS#:
DRIVER’S LICENSE #
DRIVER’S LICENSE STATE:
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
DRIVER’S LICENSE PHOTO (FRONT AND BACK)
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of
DATE OF BIRTH:
-
Month
-
Day
Year
Date
HOW MANY YEARS AT FIRM:
MARRIED
UNMARRIED
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Month-end Accounts Receivable and Accounts Payable report (Excel File)
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Detailed by Invoice and Aged by Invoice Date
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Customer List (Excel File)
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Including contact name, address, phone number & email address
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Bank Statements from the previous three months
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Debt Schedule
*
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IMPORTANT INFORMATION ABOUT PROCEDURES FOR OBTAINING A FACTORING LINE FROM WIDEQ
TO HELP THE GOVERNMENT FIGHT THE FUNDING OF TERRORISM AND MONEY LAUNDERING ACTIVITIES, FEDERAL LAW REQUIRES ALL FINANCIAL INSTITUTIONS TO OBTAIN, VERIFY AND RECORD INFORMATION THAT IDENTIFIES EACH PERSON WHO OPENS AN ACCOUNT. WHAT THIS MEANS FOR YOU: WE WILL ASK FOR YOUR NAME, ADDRESS, DATE OF BIRTH AND OTHER INFORMATION THAT WILL ALLOW US TO IDENTIFY YOU. WE WILL ALSO ASK TO SEE YOUR DRIVER’S LICENSE OR OTHER IDENTIFYING DOCUMENTS.THE INFORMATION SUBMITTED HEREIN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND IS SUBMITTED TO WIDEQ FINANCIAL LLC TO INDUCE WIDEQ TO PROVIDE FINANCING TO APPLICANT. THE UNDERSIGNED, ON BEHALF OF THE APPLICANT AND ITS OWNER(S),HEREBY (A) AUTHORIZES WIDEQ AND ANY OF ITS EMPLOYEES, AGENTS AND REPRESENTATIVES TO REQUEST AND OBTAIN ANY RECORDS AND/OR OTHER INFORMATION RELATIVE TO THE APPLICANT AND THE OWNER(S) OF A CRIMINAL OR CIVIL NATURE (INCLUDING ANY CREDIT REPORTS OR OTHER SUCH RECORDS AND/OR INFORMATION ON THE CREDITWORTHINESS OF THE APPLICANT AND ITS OWER(S)), (B)RELEASES AND INDEMNIFIES WIDEQ, ITS OWNERS, OFFICERS, EMPLOYEES, AGENTS AND REPRESENTATIVES, AS WELL AS ANY PARTY SUPPLYING SUCH RECORDS AND INFORMATION TO WIDEQ, FROM ANY LIABILITY WITH RESPECT TO REQUESTING, OBTAINING AND/OR SUPPLYING SUCH RECORDS AND OTHER INFORMATION ON THE APPLICANT AND (C) AUTHORIZES WIDEQ TO FILE A UCC ON THE APPLICANT. I AUTHORIZE MEGED FUNDING GROUP TO SHARE MY INFORMATION WITH WIDEQ FINANCIAL LLC FOR THE PURPOSE OF EVALUATING AND FACILITATING FINANCING OPPORTUNITIES.
Referred By:
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Who sent you our way?
Name
*
First Name
Last Name
Signature
*
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