Business Finance Company Profile

BUSINESS INFORMATION

Legal Name of Your Business

Current Business Address

City County St Zip

Entity Type  Corporation  LLC  Partnership  Sole Proprietorship

Years in Business Number of Employees Tax Identification Number -

Business Phone ( ) Business Fax ( ) Cell ( )

E-Mail Address Company Web Site

Briefly, what does your company do?

BUSINESS ACCOUNTS & LOAN INFORMATION

Dollar Volume of Accounts Now Open? $ (Please attach a Current Aging Report)

Average Monthly Sales $ Previous Year’s Annual Sales $

Average Profit Margin % Bad Debt Write-off last Year $

Average Invoice Size $ Number of Active Customers

What are your normal terms of payment granted to your customers?

Do you have any existing loans outstanding?  Yes  No If so, please complete the following.

Name of Bank or lender Loan Amount $

Name of Loan Officer Telephone ( )

Name of Bank or lender Loan Amount $

Name of Loan Officer Telephone ( )

Name of Bank or lender Loan Amount $

Name of Loan Officer Telephone ( )

Name of your accounts receivable manager

Phone or extension ( ) E-Mail

President / Owner First Name Middle Init. Last Name

Home Address

City County State Zip

Date of Birth Home Telephone ( ) Cell ( )

Personal E-Mail

Vice-Pres. / Co-Owner First Name Middle Init. Last Name

Home Address

City County State Zip

Date of Birth Home Telephone ( ) Cell ( )

Personal E-Mail

Secretary / Treas. First Name Middle Init. Last Name

Home Address

City County State Zip

Date of Birth Home Telephone ( ) Cell ( )

Personal E-Mail

Do any of your principals have any personal tax liens or judgments outstanding.  Yes  No

If so, please explain the circumstances, payment plans, etc.

Have any of your principals ever been arrested for a felony?  Yes  No

If yes, please explain

Have any of your principals ever filed for bankruptcy?  Yes  No

If yes, please provide dates of filings

ADDITIONAL INFORMATION

Does your business have any pending litigation?  Yes  No If yes, please explain.

Does your business have any tax liens or back taxes owed?  Yes  No If yes, please explain.

BANKING INFORMATION

Name of your bank. (Business Checking Account)

Address

City State Zip

Bank Contact Phone ( )

TRADE INFORMATION

Please provide the names of your three largest customers

Customer Name Monthly Sales Volume $

Customer Name Monthly Sales Volume $

Customer Name Monthly Sales Volume $

We fully understand that by submitting this application, Factor, Lender, or its Assigns are under no obligation to provide financing or to provide
any services whatsoever. It is further understood that Factor, Lender, or their Assigns will provide financing only after the execution of a Master
Purchase and Sales Agreement or similar document is executed.

With the following signature, applicant hereby authorizes its suppliers, customers, accountants, and attorneys to provide any necessary support-
ing documents as required to facilitate this business financing application.

A facsimile copy of this authorization and document may be accepted as an original.

Signature Print Name Date

BROKER if applicable