Broker Quick Referral Form

Company Being Referred

Business Name:

Contact Name:

Title:

Street Address:

City:

State:

Zip Code:

Country:

Phone:

If outside USA, country code:

Fax:

Email:

Web site:

How did you find us?

If "Other" please describe:

Please provide a brief description of your company.

Are Your Customers: Domestic Import Export

What is your average monthly sales volume?

How much of your average monthly billing do you wish to factor? (%)

Have you ever factored your receivables? Yes No

If yes, with whom:

Total Accounts Receivable:

Receivables > 90 days from invoice date:

Does the Company or its Owners have any judgements or liens filed against them?
Yes No

Does the Company or its Owners have any pending law suits against them?
Yes No

Do you have any outstanding loans?
Yes No

If yes, name of Financial Institution:

Balance Owed:

Do you have any UCC Filings?
Yes No

If yes, with whom:

Or are your receivables pledged as collateral: Yes No

Please List Company's 5 Largest Customers You Wish To Factor (Note: Customers will NOT be contacted initially)

Customer 1

Address:

City:

State:

Zip Code:

Monthly Sales: $

Average Invoice Amount: $

Customer 2

Address:

City:

State:

Zip Code:

Monthly Sales: $

Average Invoice Amount: $

Customer 3

Address:

City:

State:

Zip Code:

Monthly Sales: $

Average Invoice Amount: $

Customer 4

Address:

City:

State:

Zip Code:

Monthly Sales: $

Average Invoice Amount: $

Customer 5

Address:

City:

State:

Zip Code:

Monthly Sales: $

Average Invoice Amount: $

Message:

They are interested in: Domestic Factoring Purchase Order Financing International Factoring
Government Factoring Construction Factoring Business Loans Trade Financing

Broker Information

Title:

First Name:

Last Name:

Company Name:

Address1:

Address2:

City:

State:

Zip Code:

Country:

Phone:

If outside USA, country code:

Fax:

Email:

Web site:

(SPAM Security) 54 divided by 9 is:

Are you Eligible for Factoring?

Broker Quick Referral Form