Accounts Receivable Factoring

Thank you for your interest in accounts receivable factoring.

In order to provide you with specific fee and program information we will need the following form completed.

It is not necessary to complete the entire form at this time – providing basic information about your business and customer base are sufficient in most cases for us to provide you an initial quote.

Proposals are offered free of charge and at no obligation to you. All inquiries are confidential.



Company Information
Company Name:
Trade Name or DBA:
Corporation Type:
Federal Tax ID:
Date Business Started:
Address:
City:
State:
Zip:
Email:
Phone Number:
Fax Number:
Description of products or services:
Normal Sale terms:
Avg. Returns / Discounts (%):
# of active customers:
# of invoices per month:
Average invoice amount:
Prior year gross sales($):
Current year projected sales($):
What is the gross ($) amount of invoices that you intend to factor each month?:
Have you ever factored your Accounts Receivable before?
Are you bonded?
Are payroll taxes current?
Are federal / state taxes current?
Has the applicant or its principal(s) ever been arrested or convicted of a felony?
Any bankruptcy, judgments, tax liens or pending lawsuits?
Any commercial loans?

Factoring Prospects

 List up to 8 current or future customers you wish to factor - customers will not be contacted without your permission.

Prospect #1
Company Name:
Phone:
Address:
City:
State:
Zip:

Prospect #2
Company Name:
Phone:
Address:
City:
State:
Zip:

Prospect #3
Company Name:
Phone:
Address:
City:
State:
Zip:

Prospect #4
Company Name:
Phone:
Address:
City:
State:
Zip:

Prospect #5
Company Name:
Phone:
Address:
City:
State:
Zip:

Prospect #6
Company Name:
Phone:
Address:
City:
State:
Zip:

Prospect #7
Company Name:
Phone:
Address:
City:
State:
Zip:

Prospect #8
Company Name:
Phone:
Address:
City:
State:
Zip:

Ownership Information

 Please list all owners having a 20% or greater ownership interest

Owner #1
First Name:
Last Name:
Address:
City:
State:
Zip:
Email:
Phone Number:
SSN:
Ownership %:

Owner #2
First Name:
Last Name:
Address:
City:
State:
Zip:
Email:
Phone Number:
SSN:
Ownership %:

Owner #3
First Name:
Last Name:
Address:
City:
State:
Zip:
Email:
Phone Number:
SSN:
Ownership %:

Owner #4
First Name:
Last Name:
Address:
City:
State:
Zip:
Email:
Phone Number:
SSN:
Ownership %:

Owner #5
First Name:
Last Name:
Address:
City:
State:
Zip:
Email:
Phone Number:
SSN:
Ownership %:

Supporting Documents

 Please attach electronic copies of:
AR Aging Report:
Sample Invoice:
Articles of Incorporation: