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Company Information
Legal Business Name:
Primary Address:
City:	State: Zip:
Telephone:	Fax:
Web Address:

Date Business Established:	(mm/dd/yyyy)
Application Contact:
Contact Telephone:
Contact Email:

Tax Information
Federal Tax ID:	Number of Employees:
Date of 941 Filing:	(mm/yyyy)
Federal Tax Past Due?:	Yes No
Liens/Levies filed?:	Yes No
Quarter:	Year:
Amount Past Due:	$
State Tax Past Due?:	Yes No
Liens/Levies filed?:	Yes No
Quarter:	Year:
Amount Past Due:	$

Accounts Receivable Information
Total Sales Last 12 months:
Terms of Sales:
Average Invoice Amount:
Amount of Receivables Currently Open:
Average Number of Invoices per Month:
Number of Customers:
Amount you intend to factor each month:
Amount of credit losses in last 3 years:
Maximum Invoice Amount:
Have you financed or factored receivables before?:	Yes No
Name of Fnancial Institution:
Address:
City	State: Zip:
Contact Name:
Telephone:
Email:
Dates:

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