Contact

Title

Address

City, ST, Zip

Office Tel

Cell

Fax

Email

Web Site

Industry/Business Description

Avg. mo. volume
to factor

Avg. invoice size
($ amount)

# of customers
to factor

How long in business

1-4 customers to factor (for credit research only; they will NOT be contacted).
Be sure company names are spelled correctly.

Company: Address: City ST Zip: Phone #: Approx. mo. volume: $ Usual # of days for pmt: Company: Address: City ST Zip: Phone #: Approx. mo. volume: $ Usual # of days for pmt: Company: Address: City ST Zip: Phone #: Approx. mo. volume: $ Usual # of days for pmt: Company: Address: City ST Zip: Phone #: Approx. mo. volume: $ Usual # of days for pmt:

Business Type

Sole Proprietor S Corporation C Corporation LLC Partnership

  If Corp. or LLC,
state of corporate
registration

FEIN #

Owner’s Date of Birth

First 5 digits of SS #

Do you have any:

  Current Bank Loans
or Lines of Credit

No Yes

  Tax Liens
or Other Liens

No Yes

  Pending Litigation
or Existing Judgments

No Yes

  Criminal Record

No Yes

  If Yes to any above
  please describe

Are your:

  State Taxes current

Yes No

  Federal & Payroll
Taxes current

Yes No

  If No please describe

How did you find us?

(Please Select) Broker Consultant Other Factor Web Search SmallFactor.com ACFA Friend/Associate Other

Name of person
or company who
referred you

Name of person
submitting this form

Submitter’s Phone

The foregoing information is provided by an authorized company representative or broker consultant, and is true and correct to the best of my knowledge.

Upon clicking the Submit and Authorize button, Dash Point Financial Services or its agents are authorized to verify and investigate any or all of the foregoing statements. Dash Point Financial Services is granted the right to procure credit information pertaining to all principals listed in this application.