DEALER APPLICATION

Sales: 800-735-3247

   
Contact Name:
*
Company Name:
*
DBA Name:
Address 1:
Address 2:
City:
State:
Zip Code:
Tele:
*
 - -
Mobile:
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Fax:
- -
Email Address:
*
Company Established Date:
 / / (mm/dd/yyyy)
State of Incorporation:
Federal Tax ID:
 
Organization Type:
Industry Type:
Briefly Describe Your Business:
   
Tax Liens on File:
             
Bankruptcy on File:
 
Gross Sales Previous Year:
Projected Sales Current Year:
Average Monthly Sales:
How Much Do You Want To Factor Monthly:
Have You Ever Factored Receivables Before :
            Yes, with whom:
Are Any of Your Accounts Receivables Currently Being Held  As Collateral:
            Yes, with whom:
What Terms (Months) Do You Offer:
What APR (Interest Rate) Do You Offer:
What Type Of Contract Do You Use:
Additional comments: