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Company Name

Contact Person
Title
Phone Fax
Cellular Phone State of Incorporation
Address City
State
Zip Code
Country    
E-mail
Company Structure
How soon do you need to get funded?
Any Federal or State Taxes Past Due? Yes   No
If Yes, type amount: $
Do you have a lien filed? Yes   No

If Yes, briefly describe:

Do you have any loans where you pledge your receivables as collateral?

Yes   No
If Yes, to whom?   
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): $
Do you want to factor existing receivables? Yes   No
If Yes, type amount: $
Please describe what your company does:
   

   

 

 
 
 
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