Online Factoring Application

Ready to get started with invoice factoring? We invite you to use our confidential online factoring application and company profile.

The information will be sent electronically and our company will contact you shortly. We make every effort to respond by the next business day.

An application takes an average of 10 days to process assuming timely receipt of information and supporting documentation. We promise to keep you informed every step of the way and you are welcome to contact us at anytime for updates.

Factoring Services Application

Company
This field is for validation purposes and should be left unchanged.
Company*
Your Name*
First Last
Title
Email*
Business Phone Number*
Cell Phone Number
Fax Number
Website
Physical Business Address
Street Address Address Line 2 City State ZIP Code
Is Your Mailing Address the Same?
- Yes
- No
Mailing Address (if different than physical address)
Street Address Address Line 2 City State ZIP Code
Years in Business
How Did You Hear About Us?
Accounts Receivable Information
Type of Business (Please describe your products or services.)
Sales Volume
Monthly Sales Volume Amount Billed Last 30 Days Amount Billed Last 12 Months
Invoice Averages
Average Invoice Size $ Invoices Per Month # Customers Per Month #
Amount You Would Like To Factor Each Month
Have You Used Invoice Factoring Before?
- Yes
- No
If yes, please provide name of previous factoring company.
Balance of Oustanding Receivables
Receivable Balance Status
Current 0-30 days 31-60 Days 61-90 days Over 90 days
Average Number of Days to Collect
Write-off Percentage for Bad Debt
Business Information
Legal Name of Business
Trade Names or DBA (please list any used)
Legal Form of Business
If other, please describe.
State Where Business Was Organized
Year Business Was Organized
Federal Tax ID
DUNS Number (if any)
Ownership Information
Name Address % of Ownership SSN (may provide later)

(Please provide legal name, home address, and percentage of ownership. Select the + sign to add additional owners. The SSN may follow at a later time if you prefer.)
Please List and Describe Balances On Existing Financing

Please include any loans, lines of credit, or receivable financing now outstanding whether private or commercial.
Are all Federal and State taxes paid current (income tax, payroll tax, etc.)?
- Yes
- No
Please list any amounts due for State or Federal Taxes including any liens and payment terms to the IRS.
Are there any judgments, liens, bankruptcy filings, collections, felony convictions, or pending litigation against the company or owners?
- Yes
- No
If yes, please describe and explain.
Additional Documentation
Customer Information
Name Address Monthly Volume Avg. Days to Pay

Please provide information on the customers you would like to factor. This is for initial research and they will not be contacted at this time. You may also forward this information by email or fax transmittal. Please select the + to add additional customers.
Please upload an A/R aging report or forward via email or fax.
Accepted file types: xls, xlsx, txt, csv, pdf, Max. file size: 300 MB.

You may upload a file in xls, xlsx, txt, csv, or pdf format.
Additional Comments, Information, or Questions
Authorization and Acknowledgement
The foregoing information is provided by an authorized company representative for a commercial transaction and is true and correct to the best of my knowledge. Factoring Company or its agents are authorized to verify and investigate any or all of the foregoing statements including the right to procure credit information pertaining to all principals listed in this application. The undersigned understands the submission of this application does not mean a factoring transaction will be approved and additional documentation may be requested including an A/R aging report. A decision is usually reached within 10 days assuming timely receipt of information. A written proposal with terms will be provided by the Factoring Company for review and approval.
I have read the authorization and acknowledgment and would like to submit this form.*
First Name Last Name Title Date

Name	Address	% of Ownership	SSN (may provide later)

Name	Address	Monthly Volume	Avg. Days to Pay

Factoring Services Application

Accounts Receivable Information

Business Information

Additional Documentation

Authorization and Acknowledgement

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