Application

Please fill out this On-Line Application or Click here to get a PDF Paper Application to fill out
and Fax back to Us: (561) 549-0156

Name of Company:

Street Address:

City, State & Zip:


Principal Contact:

Email:

Telephone:

FAX:

Company is a: Year Established:


Principals:

(All Stockholders with 10% or more if shares,
Officers, Directors, Partners or Owners).


(Principal 1) Name:

Title:

SS#:

Street Address:

City, State & Zip:

(Principal 2) Name:

Title:

SS#:

Street Address:

City, State & Zip:

 

(Principal 3) Name:

Title:

SS#:

Street Address:

City, State & Zip:


Gross Sales:

2000 2001 2002 2003

Number of Employees:


Principal Product, Services, etc:

Typical Invoice Terms:

Average Accounts Receivable Balance: 30 60 90

Amount of Invoicing to be Factored:

Number of Customers to be Factored:

Average Invoice Amount:

Are You Now Using Factoring:

Have You Used Factoring in the Past:

Your Name:

Your Title:

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