USE THIS SHORT-FORM FOR: Factoring / ABL / Equipment / Inventory / Commercial Loans 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 Accounting Business to Business Distribution Fashion-Apparel Freight Brokerage Law Manufacturer Medical / Healthcare Printing Security / PI Firms Service Staffing / Perm Placement Staffing / Temp Placement Staffing / Temp and Perm 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 TYPE OF FINANCING REQUESTED . 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 . 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) . FOR A LINE OF CREDIT OR TERM LOAN (If Applicable) Other Collateral - Check all that apply Equipment Value: Inventory Value: Real Estate Type of Real Estate Apartment / Multifamily Affordable Housing Assisted Living Facility Carwash Casino Condo-Conversion Congregate Care Farm Gas Station W/ C-Store Gas Station W/O C-Store Hospital Hotel - Full Service Hotel - Limited Service Industrial Property Mixed-Use Motel Nursing Home Office Building Rehab Clinic Restaurant Retail Center Self-Storage Facility Seniors Housing Sports Facility Specialty Property Vacant Land (Commercial) Warehouse Other Value: Other Value: If Other, Explain 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) HOW MANY OTHER LENDERS HAVE SEEN THIS DEAL? HOW DID YOU HEAR ABOUT US? -----------------------> Please Select One Attorney Bank Other Lender Broker CPA Alta Vista AOL Ask Jeeves Excite Google HotBot Jayde Lycos MSN Overture Yahoo YellowPages Other Our Corporate Factoring Group Division thanks 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 Factoring Group Division or assigns with its initial evaluation of your request, and in no way implies a commitment or obligation to provide financing or service. All requests are subject to qualification and final approval. We hope to be your source for all your factoring needs. Again, thank you.
USE THIS SHORT-FORM FOR: Factoring / ABL / Equipment / Inventory / Commercial Loans
COMPANY INFORMATION
Anticipated Monthly Factoring
Loan Amount
If Other, Explain
Are You Factoring Now or Factored in the past?
If Factoring Now
If Factored in the Past
Our Corporate Factoring Group Division thanks 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 Factoring Group Division or assigns with its initial evaluation of your request, and in no way implies a commitment or obligation to provide financing or service. All requests are subject to qualification and final approval. We hope to be your source for all your factoring needs. Again, thank you.