An asterisk (*) indicates a required field.
* Business name:
* Street address:
* City:
* State:
* Postal code:
* Phone:
Fax:
Web address:
* Date company was established: (mm/dd/yyyy)
* Registered in what state?
* Check one: Corporation Partnership Sole Proprietor
* Type of business:
Trade names and DBAs:
Role: Select an option President Sole Proprietor Senior Partner
Ownership: %
* First name:
* Last name:
Home street address:
City:
State:
Postal code:
Home phone:
SSN:
First name:
Last name:
Federal ID number:
Number of employees:
Name of bank:
Routing number:
Account number:
Premises: Sq. Ft.
Local:
National:
International:
Method of distribution: Sales Reps Trade Shows Personal Network
Your normal terms to your customers:
Average invoice: (USD)
Annual sales volume:
Have you factored before? No Yes
If yes, which factor(s) have you used?
Are any of your receivables pledged as collateral? No Yes
If yes, pledged to whom?
Are there any lawsuits pending involving the company or any of the principals? No Yes
If yes, please detail:
Accounts Receivable: (USD)
Inventory:
Accounts Payable: (USD)
Loans, Notes Payable: (USD)
Other Liabilities:
Who will be our contact person at your office?
Contact title:
Contact phone:
Contact email address:
The above statements are true and accurate to the best of my information and belief. This serves as my permission for the release of any information regarding this application for the purposes of credit investigation. I understand that the submission of this application by the undersigned does not obligate D.S.A Finance Corporation to provide any financial service or funding.
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