Please complete our secure on-line Accounts Receivable Financing application and submit the form by clicking the button below. Or print out the form, complete and fax it to (770) 240-8450. We will contact you within 24 hours with a proposal.



COMPANY INFO SECTION:		  
Legal Name of Business:
Trade Name:
Primary Business Address:
City, State, Zip:
Contact & Title:
Telephone:
Fax:
E-Mail:
Company is a:
If Incorporated, in what state:
Federal Tax ID Number:
Date Business Started:

ACCOUNTS RECEIVABLE SECTION
Total Accounts Receivable outstanding:
Total Receivables, 0-30 Days:
Total Receivables,31-60 Days:
Total Receivables, 61-90 Days:
Total Receivables over 90 Days:
Average Monthly Sales:
Amount you wish to Receive Now:
   
PRINCIPLE INFORMATION:  
Name:
Title:
Percent of ownership:
   
GENERAL INFORMATION:
Has your company ever used Accounts Receivable Financing before: No ~Yes
Are there any outstanding loans: No ~Yes
Are there any Federal or State taxes Delinquent: No ~Yes
Are there any judgments or liens now pending: No ~Yes
Has the company or principle ever filed for bankruptcy: No ~Yes
Has any of the principles been convicted of a felony: No ~Yes
If yes to any of the above, Please explain:
Please provide any additional information that would be helpful:
 
 


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