Date: | | Title: | |
| Owners Name: | | Phone: | |
| Company Name: | | Fax: | |
| Address: | | Mobile: | |
| City, State, Zip: | | Email: | |
| Date of Birth: | | Referred By: | |
| |
| Brief Description of Business | |
| |
| Company Type: | Sole Propeprietorship Partnership
LLC Corporation |
| |
| Federal Tax ID: | | | |
| |
| How Long in Business/Industry: | |
| Gross Revenue Last 12 Mos.: | |
| Approx. # of Customers: | |
| Average Invoice Size: | |
| Desired Amount to Factor: | |
| monthly: | |
| annually: | |
| Are you currently factoring? | |
| Have you ever factored before? | |
| If Yes, with whom? | |
| Are your receivables currently pledged as collateral: | Yes No |
| |
| Bank Information/Reference: | Company Owners/Officers: |
Name of Bank: | |
|
| Checking Acct. No: | |
| Routing No: | |
| Contact Person: | |
| Phone: | |
| The foregoing information is true and correct to the best of my knowledge and is given to induce Phoenix Capital Group, LLC to consider entering into a financing agreement with this company. I hereby authorize Phoenix Capital Group, LLC or its agents to verify and investigate any or all of the foregoing statements, including but not limited to my/our credit worthiness and financial responsibility, in any way they may choose. I/We grant Phoenix Capital Group, LLC the right to procure any and all credit reports pertaining to any party listed in this application, including but not limited to, all principals of the company. I/We grant Phoenix Capital Group, LLC or its agents the right to file a UCC-1 Financing Statement listing all assets as the collateral description. |
| Agreed and consented to | |
|
