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

BROKER INFORMATION
First Name:
Last Name:
Date:
Company:
Title:
Address:
City:
State:	Please select a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New England New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Phone:
Fax:
Email:

CONTACT INFORMATION
* First Name:
* Last Name:
* Email:
* Legal Name of Entity:
Title:
* Address:
* City:
* State:	Please select a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New England New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
* 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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