Equisource Funding Corporation - working capital, factoring, business finance, cash flow, accounts receivable.

application request form

Application for Factoring Agreement
Please complete the application below. Upon receiving this preliminary application request form, a company representative will get back to you promptly.

General Information
Legal Name of Business
Trade Name
Federal ID#
Office Address	Street	City					County
	State					Zip
Mailing Address	Street	City					County
	State					Zip
	Telephone	Fax					Toll Free
	Email
	Date Established
Company Structure	Corporation	Year State					Partnership Proprietorship
	Other Explain:
Has there been a change of owners in the past year? No Yes
	If yes, explain
Has the company ever changed its name? No Yes
	If yes, explain
Brief description of business or primary product:
Name of Primary Bank					Account Officer
Telephone Number					Account Number

Individual Information - All Officers, Directors, Principals, please complete the following information:
Full Name:	First	Last					Middle
Home Address	Street	City					County
	State					Zip
	Home Phone	SS#					DL# / State
	Date of Birth		% Ownership			Title (If Any)
Full Name:	First	Last					Middle
Home Address	Street	City					County
	State					Zip
	Home Phone	SS#					DL# / State
	Date of Birth		% Ownership			Title (If Any)
Full Name:	First	Last					Middle
Home Address	Street	City					County
	State					Zip
	Home Phone	SS#					DL# / State
	Date of Birth		% Ownership			Title (If Any)
Accounts Receivable Information
Current receivables now outstanding: $ 1-30 $ 30-60 $ >60
Average number of invoices per month				Average invoice amount $
Total Billings: $ During last 30 days $ Previous 12 months
Annual bad debt write off: $				Do you deliver from purchase orders? Yes No
Do you work from contracts? Yes No				Any progressive billings? Yes No
Consignments? Yes No				Guarantees? Yes No
Historical Information
Has this company ever been sold, factored or pledged its receivables? Yes No
Are the company's receivables currently being sold, factored or pledged? Yes No
Has any officer, owner or director been associated with a company that has previously factored its receivables? Yes No
Is this company now, or has it ever been, in Bankruptcy? Yes No
Is this company now, or has it ever been, in Bankruptcy? Yes No
Are any Federal and/or State taxes past due? Yes No If yes, how much?$

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