Client Application

     
  Registered Legal Business Name & dba if applicable:
  Phone
  Fax
  Business Address
  County
 
City State Zip
  Type of Business
Sole Proprietor Partnership Corporation LLC
     
  Principal 1  
  Name
  Title
  DOB
  Home Street Address
 
City State Zip
  % Owned
  Home Phone
     
  Principal 2  
  Name
  Title
  DOB
  Home Street Address
 
City State Zip
  % Owned
  Home Phone
  Please list any additional principals.
  Have any officers or owners of your company been convicted of a felony?
  Have any officers or owners of your company been involved in a bankruptcy?
     
     
  Accountant and Attorney Information
  Name of Accountant
  Phone #
  Fax #
  Name of Firm
  Street Address
 
City State Zip
     
  Name of Attorney
  Phone #
  Fax #
  Name of Firm
  Street Address
 
City State Zip
     
  Tax Information  
  Federal ID Number
  Number of Employees
  How often do you remit 941 Payroll Taxes?
  Do you have any Federal or State Taxes past due?
  If yes, has a lien been filed?
  If so please list the
type, quarter/year and amounts:
     
  Banking Information  
  Business Checking Account
  Name of Bank
  Date Account Opened
  Account #
  Street Address
 
City State Zip
  Name of Banker
  Phone Number
  Fax Number
     
  Business Loan Account
  Name of Financial Institution
  Account #
  Street Address
 
City State Zip
  Phone #
  Fax #
  How long with institution?
  Loan Amount
  Collateral
     
  Personal Account of:
President Proprietor Partnership
  Name of Bank
  Date Account Opened
 

Street Address
 
City State Zip
  Checking Account #
  Phone #
  Fax #
     
  Supplier Information  
  Names of Principal Suppliers Product Supplied Phone
  A
  B
  C
  D
  Do you lease your business space?
 
  Period of present Lease?  
  Name of Landlord  
  Street Address  
 
City State Zip
  Monthly Rent  
  Phone #  
  Fax #  

  Receivables Information  
  What is the purpose of the funds to be generated from factoring?
  Total A/R
  Average Monthly Sales
  Number of Customers
  What are your invoice terms?
  Monthly Sales Volume
  Maximum anticipated factoring Volume?
  Have you ever factored before?
  If yes with whom?
  Are your receivables pledged as collateral?
  If yes, pledged to whom?
  Are there any other commercial Loans/Leases outstanding?
  If yes, please list:

   
     
 

afc client application