Our detailed application helps us to speed up the process for you and avoids going over many questions when we contact you on the phone. Also, if you provide us by e-mail or fax with support information and documents which we specify later on this application, then we will even gain more time and you will be very close to your first funding!

 
Bold indicates required fields.
Company Name
Other trade names and/or DBA Street Address
City State
Country Zipcode
How long at Above Address If less than 3 months, provide previous address
Phone Fax
E-mail Web Site
Business Legal Structure:
If Corporation, State of Incorporation:
If Corporation, name of secretary:
Tax ID # # of Employees
If Sole Proprietorship, is owner married? Yes   No
If Yes, spouse's full name:
Describe type of goods and services sold:
Years in Business:
How soon do you need to get funded?
Amount you would like to factor per month?
Do you want to factor existing receivables? Yes   No
If Yes, how much? $
Have you or your company filed for bankruptcy? Yes   No
If Yes , when, what chapter, status?
 
OFFICERS, OWNERS OR PARTNERS
Shareholder's Name # 1 Title & Percentage Owned
Home Street Address
City State
D.O.B. SSN#
Home Phone Nearest Relative Name/Phone/Relation
 
Shareholder's Name # 2 Title & Percentage Owned
Home Street Address
City State
D.O.B. SSN#
Home Phone Nearest Relative Name/Phone/Relation
 
Shareholder's Name # 3 Title & Percentage Owned
Home Street Address
City State
D.O.B. SSN#
Home Phone Nearest Relative Name/Phone/Relation
 
ABOUT YOUR ACCOUNTS RECEIVABLE
Any Federal or State Taxes Past Due? Yes   No
If Yes, type amount
Has a lien been filed? Yes   No
Do you have a payment plan? Yes   No
Monthly Payment $ I.R.S. Agent Name
Phone Number  
Do you have any loans where you pledge your receivables as collateral? Yes   No
If Yes, please describe
Any other Commercial Loans/Leases Outstanding? Yes   No
If Yes, please describe
Does your company have any judgments and/or lawsuits? Yes   No
If Yes, please describe
Dollar Amount of Receivables Now Open (Approx)   $
Dollar Amount of Open Receivables 1-30 Days (Approx) $
Dollar Amount of Open Receivables 31-60 Days (Approx) $
Dollar Amount of Open Receivables 61-90 Days (Approx) $
Anticipated monthly factoring volume (Approx)  $
  Avg. Monthly Sales
Avg. Invoice Amount $     
Have you factored/financed receivables before? Yes   No
If Yes, please describe
Are you currently factoring/financing your receivables? Yes   No
If Yes, please describe
If Yes, why are you unhappy with your current factor?
 
COMPANY BANKING INFORMATION
Bank Name City & State
Acct. No. Routing Number
or ABA
 
TRUCKING OR TRANSPORTATION COMPANY
US DOT # MC #
Describe your trucking business :
Number of Power Units Running (including owner operators)
Number of Power Units you plan to add over the next 6 months
 
SIGNATURE
The undersigned hereby represents and warrants that the information contained herein is true and correct and is given to 1 st Financial Factoring to induce FFF or its independent funding sources to consider entering into a factoring agreement with this company. This serves as my permission for the release of any information to FFF or its independent funding sources regarding this application for the purpose of credit investigation. The undersigned hereby authorizes FFF or its independent funding sources the right to verify and investigate any and all of the foregoing statements, including, but not limited to, my/our credit worthiness and financial responsibility, it any way it may choose.
Print Name and Title Date (mm/dd/yyyy)
 
SUPPORT INFORMATION AND DOCUMENTS
Please include the appropriate support information with your completed application and submit to 1 st Financial Factoring. (Via e-mail or fax)
  1. Articles of Incorporation or Assumed Name Certificate or DBA Certificate or Partnership Agreement.
  2. Customer List (Names, Addresses, Phones, and Contact Names).
  3. Detailed Accounts Receivable Aging .
  4. Insurance Information (If applicable) :
    1. Liability Information.
    2. Workers Compensation Insurance (Temporary Employment Firms only).
    3. Cargo and Liability Insurance (Trucking Companies only).
  5. Copy of ICC or MC or DOT Authority (Trucking Companies only).
  6. Copy of driver's license (Only for Sole Proprietorship)
  7. Sample Invoice with Backup Documentation ( PO , BOL, POD, etc)
  8. Financial Statements (Optional, if available).
  9. Detailed Account Payable Aging (Optional).
  10. Most Recent Tax Returns (Optional).
  11. Copy of 941 Withholding Tax Filing for last 4 quarters and proof of payments (Optional)
  12. Copy of current PACA license (Agricultural Accounts only).
 
   
 
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