Online Application - 1-3 SignersBusiness InformationBusiness Name Date Business Started Street Address City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code Phone Number Email Address Federal Tax ID Number Type of Business Form of Organization - Select -Sole ProprietorPartnershipCorporationLLCState of Formation - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWebsite Number of Employees Accounts Receivable InformationAmount of Receivables Now Open Average Monthly Sales Terms of Sale Average Invoice Amount Are you factoring now or have you factored before? No YesIf yes, with whom? How Many Principals / Owners Are There? One Principal / Owner Two Principals / Owners Three Principals / Owners Four or More Principals / Owners, Please Contact us at 800-794-6786Principal / Owner Name Title Percentage Owned Date of Birth Driver's License Number Social Security Number Home Address City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code Email Address Mobile Number I understand that the submission of this document to America's Factors, Inc. ("AFI") indicates my intention to enter into a Security Agreement with AFI but does not obligate AFI to factor/finance or provide any financial services whatsoever. I further acknowledge that the approval to factor/finance or provide any financial services may come only after the manager of AFI approves said application and the invoices/accounts offered, in accordance with the terms of AFI's Security Agreement. The above statements are true and correct to the best of my information and belief. This serves as my permission for the release of any information by any party to AFI regarding this application for the purpose of credit investigation. I hereby authorize AFI to investigate the credit of all individuals and entities listed above. I also herein authorize AFI to contact our customers to verify the invoices submitted for factoring. Your Signature is Required Inside the Dotted Box SubmitPrincipal / Owner #1 Name Title Percentage Owned Date of Birth Driver's License Number Social Security Number Home Address City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code Email Address Mobile Number I understand that the submission of this document to America's Factors, Inc. ("AFI") indicates my intention to enter into a Security Agreement with AFI but does not obligate AFI to factor/finance or provide any financial services whatsoever. I further acknowledge that the approval to factor/finance or provide any financial services may come only after the manager of AFI approves said application and the invoices/accounts offered, in accordance with the terms of AFI's Security Agreement. The above statements are true and correct to the best of my information and belief. This serves as my permission for the release of any information by any party to AFI regarding this application for the purpose of credit investigation. I hereby authorize AFI to investigate the credit of all individuals and entities listed above. I also herein authorize AFI to contact our customers to verify the invoices submitted for factoring. Signature of Principal / Owner #1 is Required Inside the Dotted Box Principal / Owner #2 Name Title Percentage Owned Date of Birth Driver's License Number Social Security Number Home Address City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code Email Address Mobile Number I understand that the submission of this document to America's Factors, Inc. ("AFI") indicates my intention to enter into a Security Agreement with AFI but does not obligate AFI to factor/finance or provide any financial services whatsoever. I further acknowledge that the approval to factor/finance or provide any financial services may come only after the manager of AFI approves said application and the invoices/accounts offered, in accordance with the terms of AFI's Security Agreement. The above statements are true and correct to the best of my information and belief. This serves as my permission for the release of any information by any party to AFI regarding this application for the purpose of credit investigation. I hereby authorize AFI to investigate the credit of all individuals and entities listed above. I also herein authorize AFI to contact our customers to verify the invoices submitted for factoring. Signature of Principal / Owner #2 is Required Inside Dotted Box Principal / Owner #1 Name Title Percentage Owned Date of Birth Driver's License Number Social Security Number Home Address City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code Email Address Mobile Number I understand that the submission of this document to America's Factors, Inc. ("AFI") indicates my intention to enter into a Security Agreement with AFI but does not obligate AFI to factor/finance or provide any financial services whatsoever. I further acknowledge that the approval to factor/finance or provide any financial services may come only after the manager of AFI approves said application and the invoices/accounts offered, in accordance with the terms of AFI's Security Agreement. The above statements are true and correct to the best of my information and belief. This serves as my permission for the release of any information by any party to AFI regarding this application for the purpose of credit investigation. I hereby authorize AFI to investigate the credit of all individuals and entities listed above. I also herein authorize AFI to contact our customers to verify the invoices submitted for factoring. Signature of Principal / Owner #1 is Required Inside Dotted Box Principal / Owner #2 Name Title Percentage Owned Date of Birth Driver's License Number Social Security Number Home Address City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code Email Address Mobile Number I understand that the submission of this document to America's Factors, Inc. ("AFI") indicates my intention to enter into a Security Agreement with AFI but does not obligate AFI to factor/finance or provide any financial services whatsoever. I further acknowledge that the approval to factor/finance or provide any financial services may come only after the manager of AFI approves said application and the invoices/accounts offered, in accordance with the terms of AFI's Security Agreement. The above statements are true and correct to the best of my information and belief. This serves as my permission for the release of any information by any party to AFI regarding this application for the purpose of credit investigation. I hereby authorize AFI to investigate the credit of all individuals and entities listed above. I also herein authorize AFI to contact our customers to verify the invoices submitted for factoring. Signature of Principal / Owner #2 is Required Inside Dotted Box SubmitPrincipal / Owner #3 Name Title Percentage Owned Date of Birth Driver's License Number Social Security Number Home Address City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code Email Address Mobile Number I understand that the submission of this document to America's Factors, Inc. ("AFI") indicates my intention to enter into a Security Agreement with AFI but does not obligate AFI to factor/finance or provide any financial services whatsoever. I further acknowledge that the approval to factor/finance or provide any financial services may come only after the manager of AFI approves said application and the invoices/accounts offered, in accordance with the terms of AFI's Security Agreement. The above statements are true and correct to the best of my information and belief. This serves as my permission for the release of any information by any party to AFI regarding this application for the purpose of credit investigation. I hereby authorize AFI to investigate the credit of all individuals and entities listed above. I also herein authorize AFI to contact our customers to verify the invoices submitted for factoring. Signature of Principal / Owner #3 is Required Inside Dotted Box Submit For more information, contact us at:Phone: (800) 794-6786Email: info@americasfactors.com
