Factor Application Date Name of company Address Street City Phone Zip Client Contact Information Name Phone Email Business Information Nature Of Business Business Info Selection Sale of Goods Provider of Service Is sale pursuant to a Is sale pursuant to a Term Contract Purchase Order Number of Customers Annual Revenues $ Current Debt $ Are there any liens on Accounts Receivable ? Are there any liens on Accounts Receivable ? Yes No If Yes, Describe Gorss Margin % Terms of Sale Terms of Sale 30 days 60 Days Other Please Attach: Please Attach: Accounts Receivable Aging Address for top 10 customers by sales volume Choose a file Referring Broker Send