COVER LETTER
Tell us everything you know about the note/deal:

BROKER INFORMATION
First Name:
Last Name:
Date:
Company:
Title:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:

CONTACT INFORMATION
* First Name:
* Last Name:
* Email:
* Legal Name of Entity:
Title:
* Address:
* City:
* State:
* Zip:
* Phone:
Fax:

BUSINESS INFORMATION
* DBA:
* Federal Tax ID#
* Type of Business:	Corporation  Partnership  Proprietors LLC Other
* Date Business Started:
* State of Incorporation / Registration :
* Describe Type of Business:

ACCOUNT INFORMATION
* What is your average monthly volume ?
* How much of your average monthly billing do you wish to factor?
* Monthly billing administration	Internally processing Outsourced
* Have you ever factored your receivables ?	No Yes
If yes, with whom ?
* Collection procedures	Internally administered Outsourced
* Does the Applicant or its Principal(s) have any judgments or liens filed against them?	No Yes
If yes, please explain :
* Does the Applicant or its Principal(s) have any pending lawsuits against them?	No Yes
If yes, please explain :
* Are your Payroll, Federal and State Income Taxes Current?	Yes No
If No: Explain:
* How much bad debt did you write off last year?
* Is there any security interest granted that covers accounts receivable?	Yes No
If yes, please explain:
* Do you have any outstanding loans?	No Yes
If yes with whom?:
* Name of Financial Institution :
* Address of Financial Institution :
* Balance owed $
* Contact Name :
* Phone:
Fax :

BANK ACCOUNTS
* First Bank Name:
* Phone:
* Contact Name:
* Account Number:
Second Bank Name:
Phone:
Contact Name:
Account Number:

CORPORATE OFFICERS
* First Officer Name:
* Title:
* Home Address:
* City, State & Zip Code:
* Social Security Number:
* Date of Birth:
* Ownership %:
Second Officer Name:
Title:
Home Address:
City, State & Zip Code:
Social Security Number:
Date of Birth:
Ownership %:
Third Officer Name:
Title:
Home Address:
City, State & Zip Code:
Social Security Number:
Date of Birth:
Ownership %:

    

* Required Field

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