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Factoring Application Your Name: Your Phone: Company: Contact: Title: Address: City, State, Zip: Office Phone: Cell Phone: Fax: Email: Business Description: Average Monthly Sales Volume($): Average Invoice Size($): Number of Customers: Years/Mos in business? 1-3 customers to factor (For credit research only. We will not contact your customers initially): Company: Address: City, State, Zip: Phone: Approx. monthly sales: $Avg. days for payment: Company: Address: City, State, Zip: Phone: Approx. monthly sales: $Avg. days for payment: Company: Address: City, State, Zip: Phone: Approx. monthly sales: $Avg. days for payment: Business Type: Sole Proprietor S Corporation C Corporation LLC Partnership State of Corporate Registration, if corporate: FEIN#: Owner's Date of Birth: Do you have any: Current Bank Loans or Lines of Credit: No Yes Tax or other Liens: No Yes Pending Litigation or Existing Judgments: No Yes Criminal Record: No Yes If yes to any of the above, please describe: Are your: State Taxes Current: No Yes Federal & Payroll Taxes Current: No Yes If no, please explain: How did you hear about us? Any Other Questions or Comments: