A/R FINANCING FOR BUSINESS - PLEDGED OR FACTORED
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PROFILE / INFORMATION FORM
Company Name
Type of Business
Principal
Title
-- Select ---
Owner
President
Manager
Other
DOB
SSN
Office Address
City
State
-- Select ---
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 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
FTEs
Monthly Payroll
Annual Revenue
Annual Expenses
Current Assets
Current Liabilities
Long Term Debt
State of Incoporation
-- Select ---
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 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
Date of Incorporation
Tax ID #
Company Bank
Bank Phone
Bank Address, State, ZIP
Type of Financing Sought
If AR- AR Outstanding
Average Monthly AR
Types of Previous/Current Financing
Major Clients/Suppliers (if applicable)
Any liens against your revenue or accounts?
Yes
No
If YES, Please Explain
Intended Use of Financing Proceeds
Property/Facility Description (type, size, value)
Equipment Description (type, size, value)
I am interested in financing solutions
Now
Within 6-12 months
Please Call or Email Me
