www.premiumfinancesolutions.com

Client Factoring Form

Legal Name of Company (as shown on Articles of Incorporation or Partnership Agreement):
Street Address, City, State, Country, ZIP Code:
Telephone #: Fax #:
Does the company use a trade name or d/b/a?  
If yes, what is it?   
Company is a:       Other:  
PLEASE ATTACH ARTICLES OF INCORPORATION/PARTNERSHIP AGREEMENT AND/OR FICTITIOUS NAME FILING.
Date Business Started:      
State of Incorporation/Registration: 
Annual Sales Volume:        Number of Employees:    
Federal Tax Identification Number:  
Describe Type of Business:
 
What is your average monthly sales volume?   $  
How much of your average monthly billing do you wish to factor?    $  
Have you ever factored your receivable?  
If yes, with whom:  
Do the Applicant or its Principals have any judgments or liens filed against them?  
Do the Applicant or its Principals owe any back taxes?  
Amount Owed:   $  
Do the Applicant or its Principals have any pending law suits against them?  
How much bad debt did you write off last year?  $
Do you have any outstanding loans?
If yes, with whom (Name of Financial Institution):
Address:  
Balanced Owed:  $
Telephone #: Fax #:
   
Please List All Bank Accounts
Bank Name:      Account #:  
Contact Name:  Phone # :    
Bank Name:      Account #:  
Contact Name:  Phone # :    
Please List Company's 5 Largest Customers You Wish to Factor
(Note: Customers will NOT be contacted)
(1.) Company Name:  
Phone # :           City:        State:    
Monthly Sales:    $      Average Invoice Amount:   $
(2.) Company Name:  
Phone # :           City:        State:    
Monthly Sales:    $      Average Invoice Amount:   $
(3.) Company Name:  
Phone # :           City:        State:    
Monthly Sales:    $      Average Invoice Amount:   $
(4.) Company Name:  
Phone # :           City:        State:    
Monthly Sales:    $      Average Invoice Amount:   $
(5.) Company Name:  
Phone # :           City:        State:    
Monthly Sales:    $      Average Invoice Amount:   $
   
Professional References:  
Name of Attorney :              Phone # :    
Name of Accountant:              Phone # :      


The foregoing information is true and correct to the best of my knowledge and is given to Premium Finance Solutions, Inc. to induce Premium Finance Solutions, Inc. to consider entering into a factoring agreement with this company. I do, hereby, authorize Premium Finance Solutions, Inc., or its agents to verify and investigate any or all of the foregoing statements, including but not limited to my/our credit worthiness and financial responsibility in any way they may choose. I/We grant Premium Finance Solutions, Inc. the right to procure any and all credit reports pertaining to any party listed in this application, including, but not limited to, all principals of the applicant company.
AGREED AND CONSENTED TO:  
Authorized Signature*
Title
   
*Entering your complete name will represent your signature as an applicant.

     
   
   
 

Premium Finance Solutions, Inc.
1911 Foothill Blvd., #149
La Verne, CA 91750-3511
909-964-1701 Fax: 413-751-9884
E-mail: pfsolutions@adelphia.net
"Insurance Premium Finance & Commercial Lending Solutions"
We are proud to be a member of the American Cash Flow Association.








 

QUICK LINKS:
• Mission Statement
• Insurance Premium Financing
• Reasons to Sell Cash Flows
• Asset Protection
• Selling Private Mortgage Notes
• Receivable Funding/Factoring
• Structured Settlements
• Leasing
• Apply Online
















































































HOME | ABOUT US | SERVICES | SUPPORT | F.A.Q. | CONTACT US
© Copyright 2004. All Rights Reserved. Premium Finance Solutions