APPLICATION FOR FINANCING

Section 1

1. Legal Name of Company
(as shown on the ARTICLES of INCORPORATION or PARTNERSHIP AGREEMENT

Address

City

State Zip

Contact / Position

Phone

Fax

Email Address
(Required)

2. Your business is a: Proprietorship   Partnership   Corporation   Other

3. How long have you been in business?  

4. Describe your business:

Section 2
Accounts Receivable Information

5. What is your average monthly billing?  

6. How much of your average monthly billing do you wish to factor?  

7. What is the average size of your invoices?  

Smallest?  Largest?

8. Are any of your receivables progress billing? (In other words, do you bill in "as completed" phases for larger projects?) Yes   No

9. List most important major customers:
    (Name / Address / Phone / Fax)

Section 3

10. Do you have any outstanding business loans?   Yes   No

11. Are receivables pledged as collateral?   Yes   No

12. Name of institution:

     Loan amount & terms

13. Federal I.D. #

14. Do you have any current/pending tax problems?   Yes   No

     Federal balance owed:   State balance owed:

     Any liens placed?   Yes   No    Any levies placed?   Yes   No

     Do you have a payment plan?   Yes   No    Monthly Payment:

     Name of IRS Agent:    Phone:

Section 4
Bank Accounts

Bank/Branch/Phone

Address

Account #

Routing #

Section 5
General

15. Company's Attorney:

Phone:

Address:

16. Company's Accountant:

Phone:

Address:

17. Have you previously factored?  Yes   No

18. Name of previous factor: