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BUSINESS INFORMATION: Legal Business Name
Business Type
Corporation
LLC
Partnership
Sole Proprietor
Business Address
City
State
Zip Code
Phone
Email
website
Date Established
Federal Tax ID (EIN)
State Of Incorporation
CONTACT INFORMATION: Owner / Principal
Owner
Title
Social Security Number
Ownership %
Phone
E-mail
Additional Owner (If Applicable) with % ownership #1
Additional Owner (If Applicable) with % ownership #2
Industry/ Nature of Business
Current Monthly Revenue
# of Full-Time Employees
Do you have existing factoring relationship
YES
NO
If Yes, with whom
Factoring Request : Amount of Funding Requested
Average Invoice Size
Average Monthly Invoicing Volume
Number of Customers You Invoice
Typical Payment Terms
Net 30
Net 60
Net e.t.c.
Main Customer #1
Main Customer #2
Main Customer #3
DOCUMENTS TO ATTACH: Invoices, Last 3 month bank statements
you Main whom
Aging Accounts receviable reports, article of incorporation or business name
copy of Voided business check
Authorized Signer Name
*
Title
Signature
Date
Submit