Factoring Application
Company:
Contact:
Title:
Address:
City, St, Zip:
Office Tel:
Cell:
Fax:
Email:
Web Site:
Industry/Bus.
Description
Avg Mo. Volume to Factor:
Avg Invoice Size:
Number of Customers to Factor:
How Long in Business:
1-3 customers to
factor (for credit
research only;
they will NOT be
contacted).
Please spell
company names
correctly.
Company 1 Name:
Address:
City, ST, Zip:
Phone Number:
Approx Mo Volume:
Company 2 Name:
Address:
City, ST, Zip:
Phone Number:
Approx Mo Volume:
Company 3 Name:
Address:
City, ST, Zip:
Phone Number:
Approx Mo Volume:
Business Type:
If Corp. or LLC, state of corp. registration:
FEIN:
Owner's Date of Birth:
Last 4 digits of SS #:
Do you have any:
Current Bank Loans or Lines of Credit:
Tax Liens or Other Liens:
Pending Litigation or Existing Judgements:
Criminal Record:
If 'Yes' to any of the above, please describe:
Are Your:
State Taxes Current:
Federal & Payroll Taxes Current:
If 'No' to any of the above, please describe:
How did you find us?
Name of referring person or company:
Name of person submitting this form:
Your Phone Number:
The above information has been submitted 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 below, Stonebridge Financial
Services, Inc. or its agents are authorized to verify and investigate any and all
the above statements.  Stonebridge Financial Services, Inc. is granted the
right to obtain credit information pertaining to all principals listed in this
application.
Factoring Application