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Factoring Application

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Company:*
Name:*
First Last
Title:
Email:*
Business Phone Number:
Cell Phone:
Fax Number:
Message:
Website:
Physical Business Address:
Street Address City State ZIP Code
Is Your Mailing Address the Same?:*
- Yes
- No
Mailing Address:
Street Address City State ZIP Code
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
Invoices 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
Balance of Outstanding 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*
Other type of Business
State Where Business was Organized
Year Business was Organized
Federal Tax ID
DUNS Number (If any)
Ownership Information
Name
First Last
Address
Street Address City State ZIP Code
% of Ownership
Please List and Describe Balances on Existing Financing Below
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
Are there any judgements, liens, bankruptcy filings, collections, felony convictions, or pending litigation against the company or owners?
- Yes
- No
Additional Documentation
Customer Information
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.
Name
First Last
Address
Street Address City State ZIP Code
Monthly Volume
Avg. Days to Pay
Please upload an A/R aging report
Email or Fax report if you prefer.
Max. file size: 128 MB.
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.
Consent*
I have read the authorization and acknowledgement and would like to submit this form.

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Get Paid on Invoices NOW!

Discover how factoring can turn invoices into cash … FAST!
Up to 95% Advance Rates
Factoring Fees as Low as 1.5%
Working Capital Without Debt
No Long Term Contracts
Strong Financials Not Required
24 Hour Funding on Approved Invoices
You Control How Funds Are Used
Pay Bills, Fund Growth & Increase Profits!

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Benefits of Factoring

Cash Without Debt
No Long Term Contracts
Strong Financials Not Required
You Control How Funds Are Used
Pick & Choose the Invoices to Factor

Learn more about these Factoring Benefits!

(605) 645-0640

Factoring Application

Accounts Receivable Information

Sales Volume

Invoices Averages

Receivable Balance Status

Business Information

Ownership Information

Additional Documentation

Authorization and Acknowledgement

Get Paid on Invoices NOW!

Benefits of Factoring

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