Accounts Receivable Financing and Factoring Application

Business Information:

Company Name: *
Address 1: *
Address 2:
City: *
State: *
Zip: *
Country: *
Phone: *
Fax:
Website URL:

Administrative Contact Information:

Contact Name: *
Title:
Phone:
E-Mail Address:

Industry Information:

Industry:
(eg. Telecommunications)
Type of entity:
Other Type of entity:
Legal status:
Years established:
Have you factored before?
Yes No
If so, with whom?

Financial Information:

Annual Sales
Open receivables:
Approx number of customers:
Average invoice size:
Any taxes past due?
Yes No
If so, description:
Any assets now assigned,
pledged, or liened as
collateral for loans?
Yes No
If so, description:

Company Description:

Please provide a brief description of your company, its services, and your factoring needs
Security Code: *
Submit