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Company & Ownership Information

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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:
Please describe your business & the owner(s) background:

All 10%+ Individual Owners and any Corporate Ownership

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Officer/Owner #1 Name:
Officer/Owner #1 US Citizen?
Officer/Owner #1 DOB:
Officer/Owner #1 SSN:
Officer/Owner #2 Name:
Officer/Owner #2 US Citizen?
Officer/Owner #2 DOB:
Officer/Owner #2 SSN:

Billing Information

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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

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

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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

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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

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

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Electronic Signature

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