If interest in Just Factoring, please click here.

For Asset Based Lending (ABL), please complete this form below.

GENERAL INFORMATION
Legal Name of Business
Main Address
City
State	AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Select
Zip
Contact
Title	Attorney CEO CFO Controller COO CPA Director Executive VP Office Manager Owner President Sr. Vice President Vice President Assistant Vice President Other Select
Email
Phone
Fax

COMPANY INFORMATION
Type of Business	Select Your Industry Business to Business Distribution Fashion-Apparel Freight Broker Manufacturer Medical / Healthcare Printing Security / PI Firms Service Staffing Telecommunications Transportation Trucking Wholesale Distribution Other
If Other, Explain
Type of Products/Services Offered
Name of CEO
How Long In Business
Number of Employees
Type of Ownership	Corporation S Corporation Sole Proprietorship Partnership Limited Liability Company
State of Incorporation / Business Filing
Is Your Company Public or Private?	Public Private
If Public, Please Enter Symbol
If Financials Are Online? URL Here >-------->
Company Website? (If Any) URL Here >---->
Any Credit Defaults?	NoYes
If Credit Defaults, Please Explain
Any Lawsuits or Litigation Pending?	No Yes
If Litigation, Please Explain

TYPE OF FINANCING REQUESTED
Check all that apply - For Just Factoring - Click Here
Factoring (Domestic) Anticipated Monthly Factoring
Factoring (International) Anticipated Monthly Factoring
Line of Credit Loan Amount
Term Loan Loan Amount
Purchase Order Finance Loan Amount
Export Funding Loan Amount
Trade Finance Loan Amount
Other If Other, Explain
COMBINED LOAN AMOUNTS (US$)
PURPOSE OF LOAN (USE OF FUNDS)

ABOUT ACCOUNTS RECEIVABLES
If No Accounts Receivables Check Here
Dollar Amount of Receivables Now Open
Average Monthly Sales
Total Sales Last 12 Months
Total Returns last 12 months (if none put "none")
Percentage of Bad Debts last 12 Months
Approximate Number of Customers
Do You Sell on Terms of Net: 10 days 30 days	60 days 90 days
Do You Offer Early Payment Discounts: NoYes	(If yes, what percentage?%
Average Invoice Amount
Are Your Accounts Receivables Pledged as Collateral? No Yes	If YES, to whom?
IF FACTORING
Amount You Intend To Factor on Monthly Basis
Maximum Anticipated Annual Factoring Volume
Are You Factoring Now or Factored in the past?	Yes No
If Factoring Now
If Factored in the Past
OTHER COLLATERAL (If Applicable)
(Check all that apply)
Equipment	Value:
Inventory	Value:
Real Estate (Commercial)	Value:
Other	Value:
If Other, Explain

EXISTING FINANCING
Existing Financing	Select Bank line of credit Asset-based loan Line of Credit & Term Loan Self-financed Term loan Other
If Other, Explain
Total Loans Outstanding (Long Term Debt)
LAST YEAR-END FINANCIAL STATEMENT
Total Current Assets
Total Assets
Total Current Liabilities
Total Liabilities
Total Revenues
Total Cost of Goods Sold
Total General & Administrative (G&A)
Total Net Income
Net Income Before Interest, Taxes, Depreciation, Amortization (If Available)
COMMENTS:

HOW MANY OTHER LENDERS HAVE SEEN THIS DEAL?
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Thank you for submitting the online form. The person that handles your region will contact you shortly. By submitting this online form, you understand that you are providing this information for the sole purpose of assisting our Corporate Financial and Factoring Group Division or assigns with its initial evaluation of your request and does not represent or imply a commitment or obligation to provide factoring or financing. All requests are subject to final approval. Again, thank you.

If the combined ABL request is less than US$5 million, the application will be processed by our small business affiliate.