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Business Name:
Contact Name:
Title:
Street Address:
City:
State / Zip:
Country:
Phone:
Ext:
If outside USA,
country code:
City code:
Fax:
Email:
Web site:
Description:
Please provide a brief description of your company.
Are Your Customers:  Domestic
 Import
 Export
Where Are They Located:  North America
 South America
 Asia
 Europe
 Africa
What is your average monthly sales volume? $
How much of your average monthly billing do you wish to factor? (%)
Have you ever factored your receivables?  Yes     No
If yes, with whom:
Total Accounts Receivable: $
Receivables > 90 days from invoice date: $
Does the Company or its Owners have any judgements or liens filed against them?  Yes     No
Does the Company or its Owners have any pending law suits against them?  Yes     No
Do you have any outstanding loans?  Yes     No
If yes, with whom: Name of Financial Institution
Balance Owed: $
Do you have any UCC Filings:  Yes     No
If yes, with whom:
Or are your receivables pledged as collateral:  Yes     No


Please List Company's 5 Largest Customers You Wish To Factor
(Note: Customers will NOT be contacted initially)

 
Company Name:
Address:
City:
State / Zip:
Monthly Sales: $
Average Invoice Amount: $
Company Name:
Address:
City:
State / Zip:
Monthly Sales: $
Average Invoice Amount: $
Company Name:
Address:
City:
State / Zip:
Monthly Sales: $
Average Invoice Amount: $
Company Name:
Address:
City:
State / Zip:
Monthly Sales: $
Average Invoice Amount: $
Company Name:
Address:
City:
State / Zip:
Monthly Sales: $
Average Invoice Amount: $
Message:
 
I am interested in:  Domestic Factoring
 Purchase Order Financing
 International Factoring
 Government Factoring
 Construction Factoring
 Business Loans
 Trade Financing
 


 
 
 
 

 

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