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Accounts Receivable Financing Application
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Accounts Receivable Financing Application

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  • 1. Application COMPANY INFORMATION Business Name (as shown on the Articles of Incorporation) __________________________________________________________________________ Type of Legal Entity: Corporation ___ LLC ___ Partnership ___Proprietorship ___ Sub-S Corporation ___Other ________________ (Please Specify) Years in Business _____________ Date Incorporated _______________ State Incorporated _______________________________________________ Street Address of Headquarters _____________________________________________________________ County ____________________________ City, State, Zip __________________________________________________________________ Phone (________)____________________________ Type of Business ________________________________________________________________ Fax (________)______________________________ Website Address ___________________________________________________________________________________________________________ If doing business in more than one place, attach list of all other locations (full mailing address & county): Not Applicable _________ Attached _______ List Trade Names, DBAs; Assumed Names & Fictitious Names ______________________________________________________________________ Attach list of ALL Subsidiaries, Affiliates, Joint Ventures, Partnerships, etc. and indicate relationship and ownership. Attached ________ None ______ Has company ever done business under any other names not listed above? Yes __________ No __________ If Yes, under what names? __________________________________________________________________________________________________ Length of Current Ownership ______; If less than 2 years explain ____________________________________________________________________ Does the Company own any Real Estate? Yes __________ No ___________ If Yes, attach list of addresses. Number of Employees: ____________________ Annual Sales: __________________________ PRINCIPALS AND OFFICERS Please list all corporate officers and all ownership interests of 5% or more (attach additional sheet if necessary): Owner #1 Name________________________________________________________________ Soc. Sec # _____________________________ % Stock Owned_____ Home Street Address _________________________________________________________ Own ____________ Rent __________ Title____________ City, State, Zip ______________________________________________________________County____________________________ Date of Birth______________ Drivers’s License Number (include copy with application) __________________________________ Home Phone: (____)__________ Work Phone(____)_________ Cell Phone (_____)_________ E-mail address__________________ Owner #2 Name________________________________________________________________ Soc. Sec # _____________________________ % Stock Owned_____ Home Street Address _________________________________________________________ Own ____________ Rent __________ Title____________ City, State, Zip ______________________________________________________________County____________________________ Date of Birth______________ Drivers’s License Number (include copy with application) __________________________________ Home Phone: (____)__________ Work Phone(____)_________ Cell Phone (_____)__________ E-mail address__________________ Main Contact Name________________________________________________________________ Soc. Sec # _____________________________ % Stock Owned_____ Home Street Address _________________________________________________________ Own ____________ Rent __________ Title____________ City, State, Zip ______________________________________________________________County____________________________ Date of Birth______________ Drivers’s License Number (include copy with application) __________________________________ Home Phone: (____)__________ Work Phone(____)_________ Cell Phone (_____)_________ E-mail address__________________ 1
  • 2. COMPANY LOCATION INFORMATION Are you presently leasing your company headquarters? Yes___________ No__________ If yes, what is the monthly rent?____________________ Name of Landlord/Management Co. _____________________________________________________________________________________________ Street Address ______________________________________________________________________________________________________________ City ___________________________________________________________ State______________________ Zip Code ______________________ Phone Number (______) ______________________________________________________________________________________________________ Period of Lease ______________________________________________________ Monthly Rent __________________________________________ If you have inventory, is it all located here? Yes___ No ___; If No, Please Explain________________________________________________________ Any Hazardous materials stored on company property? Yes ___ No___; If Yes, Please Explain______________________________________________ ACCOUNTS RECEIVABLE INFORMATION What were your total billings/sales last fiscal year? _________________ What do you project your billings/sales to be this year? __________________ What is the average size of your bills? ___________________________How many bills to you generate per week? ____________________________ Bad Debt Charge Offs last 2 Years: $___________________ Are Sales supported by: Contracts ___; Purchase Orders _____; Other ______________ Are terms other than Net 30 granted? Yes______ No_______ If Yes, explain __________________________________________________________ Any pre-bills; bill and holds; guaranteed sales; retainage, progress billings or foreign sales? Do you buy goods from any of your customers? (Please Specify)____________________________________________________________________________________________________________ Primary Shipping Method? (common carrier, self delivery, etc.) ______________________________________________________________________ Proof of Delivery Obtained?________ Returns, Credits and Allowances Represent what percentage of sales each month? ________% Have you ever financed your receivables? Yes_____ No _____ If Yes, with whom and when?______________________________________________ TAX INFORMATION Federal Tax ID# ____________ - ________________________________________________ Fiscal Year End Date __________________________________ Date of Last Income Tax Return Filed ________________________________________ How often are Form 941 payroll taxes paid? ______________ Do you prepare the payroll taxes? _____________ If not, who does? ________________ Are any Federal, State, County or Local taxes past due or any tax liens outstanding, or have you received notice of intent to file tax liens? Yes__; No ___ If yes regarding past due taxes, how much $____________ and in what jurisdiction (state/federal etc.)? ___________________ IRS Contact _____________________________________________________________ Phone Number (_____) _____________________________ PROFESSIONAL REFERENCES Name of Accountant__________________________________________________________ Firm__________________________________________ Street Address _____________________________________________________________________________________________________________ City _______________________________________________ State _________________________________ Zip Code ________________________ Phone Number (___) ______________ Fax Number (___) _____________ E-Mail Address ______________________________________________ Name of Attorney____________________________________________________________ Firm__________________________________________ Street Address _____________________________________________________________________________________________________________ City _______________________________________________ State _________________________________ Zip Code ________________________ Phone Number (___) ______________ Fax Number (___) _____________ E-Mail Address ______________________________________________ 2
  • 3. Other Business Reference #1______________________________________________ Relationship to Company_______________________________ Street Address ______________________________________________________________________________________________________________ City _______________________________________________ State _________________________________ Zip Code ________________________ Phone Number (___) ______________ Fax Number (___) _____________ E-Mail Address ______________________________________________ Other Business Reference #2______________________________________________ Relationship to Company_______________________________ Street Address ______________________________________________________________________________________________________________ City _______________________________________________ State _________________________________ Zip Code ________________________ Phone Number (___) ______________ Fax Number (___) _____________ E-Mail Address ______________________________________________ BANKING & CREDIT INFORMATION COMPANY CHECKING ACCOUNT Name of Bank ______________________________________________________________________________________________________________ Street Address _____________________________________________________________________________________________________________ City ____________________________________________________________ State _________________________________ Zip _______________ Account Number _______________________________ Date Opened _______________________________________________________________ Phone Number (_____) _________________________ Bank Officer _______________________________________________________________ COMPANY LOAN ACCOUNT Name of Financial Institution __________________________________________________________________________________________________ Street Address _________________________________________________ City _________________________ State ______ Zip ________________ Account Number _________________________________________ Date Opened:__________________________ Bank Officer ______________________________ Phone Number (_____) _________________________ Maximum Balance $_________________________________ Present Balance $_______________________ Collateral Supporting Loan(s) _________________________________________________________________________________________________ If additional accounts, please attach a schedule. EQUIPMENT LOANS/LEASES Name of Financial Institution _______________________________________________________ Officer _____________________________________ Street Address _________________________________________________ City _________________________ State ______ Zip ________________ Phone Number (_____) _____________________ Date Opened _______________________ Term ________________________________________ Original Loan Amount ________________________Monthly Payments ________________________ Present Balance __________________________ If additional equipment loans/leases, please attach a schedule. PERSONAL ACCOUNT OF ________________________________________________________________________, Title __________________________ Name of Bank _______________________________________________________________________________ Date Opened _________________ Street Address _____________________________________________________________________________________________________________ City ____________________________________________________________ State _________________________________ Zip ______________ Account Number _________________________________________________________ Phone Number (_____) ____________________________ GENERAL INFORMATION Are there any judgments or lawsuits pending or outstanding against your company? Yes _________ No __________ If so, describe ______________________________________________________________________________________________________________ Have any of your company's corporate officers ever been convicted of any criminal offense other than a minor motor vehicle violation? Yes __________ No __________ If Yes, describe. _________________________________________________________________________________ Has the company ever filed Bankruptcy? Yes __________ No __________ If Yes, in what year? ____________________________________________ Have any of the owners declared bankruptcy? Yes _____No ______ If Yes, who and in what year? _______________-__________________________ 3
  • 4. The undersigned hereby certifies that the above information is correct and complete. As a part of the application, the undersigned hereby grants to SPECTRUM Commercial Services Company its consent and authorization to contact consumer and commercial credit reporting agencies as well as the people and organizations listed above, and any other references disclosed by such agencies, people or organizations. The undersigned also represents and acknowledges that the individuals listed above under "Principals and Officers" have, as individuals, granted their consent to SPECTRUM Commercial Services Company to contact consumer and commercial credit reporting agencies and any other references disclosed by such agencies. Please commence your due diligence work for the purpose of deciding whether to offer the financing requested by us. Please note that, in addition to any application or survey fee that may have been paid by us, we will reimburse you for your out-of-pocket costs including, but not limited to, UCC, tax lien, and judgment search fees and appraisal costs. We acknowledge that SPECTRUM Commercial Services Company has not agreed to provide financing, and shall at no time be considered to have offered or committed to any financing, loan or credit facility except in an explicit writing, dated subsequent to this application, and signed by you. Any fees paid by us are for survey and investigation only. ____________________________________________________________________ Date Signed:____________________________________________ [Print Company Name] ____________________________________________________________________ [Signature of Authorized Representative] ____________________________________________________________________ [Print Name and Title of person signing] 4

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