Online Application : Americas Factors Inc.

SSL Certificate Authority

Online Application:

Business name: *

Date Business Started:

Street Address: *

County:

City:*

State: *

Zip:*

Tel: *

Fax:

Federal ID number:

Where did you hear about us:

If Other :

Type of Business:

Form of organization:

Sole proprietor
Partnership
Corporation
LLC
State of formation:

Website:

Email:

Number of employees

PRINCIPALS

Name: *

Social Security #:

Title: *

%Own: *

DOB: *

DL #:

Home address: *

Own: Rent:

City: *

State: *

Zip: *

Telephone #: *

Cell #:

Email*:

Spouse's name:

SSN #:

RECEIVABLE INFORMATION

Amount of receivables now open:

Average monthly sales $:

Terms of sales:

Average invoice amount $:

Are you factoring now or have you factored before?

Yes No

If yes, with whom:

Any other commercial loans/leases outstanding?

Yes No --- Amount $:

The foregoing statements are true and accurate to the best of my/our knowledge. I/We hereby consent to the release of personal and business information and acknowledge that such information will be useful in qualifying me/us and the business for the requested financing. This authorization may be forwarded to third parties who are hereby authorized to release such information. I/We understand that submission of this application does not commit Americas Factors, Inc. to provide any financial services.


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