Factoring Application Company Information Legal Business Name* DBA Primary Contact*FirstLast Business Address* Street Address City State Postal / Zip Code Business Phone* Area Code - Phone Number Secondary Phone # Area Code - Phone Number Type of Business*Please Select OneCorporationLLCPartnershipSole Proprietorship Federal Tax ID #* MC # (if applicable) Industry Business Email* Email confirmation* Business Fax Area Code - Phone Number Company Principals Full Name Princple 1* Social Security #* Title/OwnershipTitle% of Ownership Home Address* Street Address City State Postal / Zip Code Phone Area Code - Phone Number Full Name Principle 2 Social Security # Principle 2 Title/Ownership 2Title 2% of Ownership 2 Home Address Principle 2 Street Address City State Postal / Zip Code Phone Principle 2 Area Code - Phone Number Operational Information Open Receivable's Amount Estimated Yearly Sales Estimated Amount to Factor Each Month Number of Active Customers Lists any business loans or lines of credit Have you Factored before?YesNo Has Company or any of its principles ever declared bankruptcy?*YesNo Any unsatisfied liens or judgements against company or any of its principles?*YesNo Are Federal, State, or withholding taxes current?*YesNoBank and Insurance Information Business Bank* Bank OfficerFirstLast Branch Phone # Area Code - Phone Number Branch Address Street Address City State Postal / Zip Code Insurance Company Agent's NameFirstLast Insurance Company's Phone # Area Code - Phone Number Insurance Company's Address Street Address City State Postal / Zip CodePlease Authorize:We hereby affirm that the above statements are true and accurate to the best of my/our knowledge and belief. This serves as my/our permission for the release of any information regarding this application to Assured Capital Funding, LLC and its authorized affiliates for the purpose of credit investigation.The undersigned also hereby consent(s) to Assured Capital Funding, LLC and its authorized affiliates to collect personal credit information, including personal credit report(s). I Agree to the above terms* Authorized Signature* Date* I Agree to adopt this typed representation of my name as my signature*SubmissionSend a copy of this message to yourself I'm not a RobotSubmitReset