Factoring & PO Funding Application

Ready for fast funding? Please fill out the safe & secure application
below.

Need a quick question answered? Please call toll-free (888) 400-5931 ext 1 or use our fast
contact form.

Company & Ownership Information

* indicates a required field

*Legal Name of Company:
(as shown on the Articles of Incorporation or Partnership Agreement)
*Legal Form Under Which Business Operates:
*Federal Tax ID:
*State of Incorporation:
*In Business Since:
*Address:
*City:
*State:
*ZIP:
*Number of Employees:
*Describe your business and the owner(s) background:

All 10%+ Individual Owners and any Corporate Ownership

* indicates a required field

*Officer/Owner #1 Name:
Officer/Owner #1 DOB:
Officer/Owner #1 SSN:
Officer/Owner #2 Name:
Officer/Owner #2 DOB:
Officer/Owner #2 SSN:

Billing Information

* indicates a required field

*Average Monthly Billing ($):
*Desired Factoring Amount ($):
*Average Invoice Size ($):
*Largest Invoice ($):
*Smallest Invoice ($):
*Do you bill in Progress stages?
*Are any of your sales Bill and Hold

Customer Information

List your 3 largest customers. Your customers will not be contacted at this time.

Customer #1

*Company Name:
Contact Name:
Address:
City:
State:
ZIP:
Phone:
Email:
Payment Terms:
Current Balance:

Customer #2

*Company Name:
Contact Name:
Address:
City:
State:
ZIP:
Phone:
Email:
Payment Terms:
Current Balance:

Customer #3

*Company Name:
Contact Name:
Address:
City:
State:
ZIP:
Phone:
Email:
Payment Terms:
Current Balance:

Financial Information

* indicates a required field

*Do you have any outstanding loans and/or advances?
Is your inventory/receivables pledged as collateral?
Name of Financial Institution:
Loan Amount and Terms:
Are your Federal, State, and payroll taxes current?
(If ‘Yes’, skip to the next section. If ‘No’, answer the following)
Federal Taxes Owed ($):
State Taxes Owed ($):
Have any liens been placed?
If yes, are you on a payment plan?
Monthly Payment ($):

Your Information

* indicates a required field

*Your First Name:
*Your Last Name:
*Your Title:
*Office Phone:
*Office Cell:
*Email:
Email 2:
How did you hear about us?

For faster funding please attach the following:

Maximum file size is 2MB for each file.

Electronic Signature

ALL fields are required

Please enter your name as it appears above to sign this application: