| Business Information |
| Business Name |
|
| Street Address |
|
| City-ST-Zip |
|
State |
|
ZIP |
|
| Phone |
|
Fax |
|
Email |
|
| Company Type |
Corporation
Partnership
Sole Proprietorship
LLC |
| Tax ID |
Federal ID# |
| Motor Carrier Number |
|
DOT# |
|
Employees / Business
Information |
# of Employees
Business Establishment Date |
| Equipment Information |
Freight Type:
# of: Tractors
Trailers
Drivers |
| Principal Information |
| Name |
|
| Title |
|
| % Ownership |
|
| Home Address |
|
| City - State - Zip |
|
| Phone - Cell - Email |
-
-
|
| Tax ID |
SSN
DOB |
| Other Principal(s) Information |
| List all pertinent information about any other principal(s) in your business |
|
| Credit/General Information |
| Tax Return Information |
Do you have any Federal or State Taxes Past Due? Yes No
If yes, has a lien been filed? Yes No
If yes, please list type, quarter/year amounts:
|
| Judgments |
Do you have any judgments against you?
Yes
No
If yes, please explain:
|
| Loans |
Do you currently have a business loan?
Yes
No
If yes, with whom?
Do you have any equipment financed?
Yes
No
If yes, with whom?
|
| Factoring Information |
| Previous Factoring |
Have you ever factored your receivables? Yes No
If yes, with whom?
If yes, when:
Avg. Monthly Sales Volume:
Avg. Bill Size:
Estimated monthly dollar you wish to factor:
Approximate number of customers you wish to factor |
| Please Briefly Explain Your Company’s Need in Detail
|
|
| Please Let Us Know How You Heard About Us? |
Word of Mouth
Brochure/Mailer
Billboard
Factoring Broker
Internet
Sales Representative
Other
If Other, Please Describe
|
| Contact Info |
When can we contact you?
and Date:
|
| Statement |
The above listed information is accurate and truthful to the best of my knowledge. I understand that this application does does not guarantee acceptance into Match Factors, Inc. This application serves as my permission for the release of any information or documents to Match Factors, Inc. for the purpose of credit investigation. I hereby authorize Match Factors, Inc. to investigate the credit of all parties listed above. |
| Additional Materials |
Please fax the following documents to Match Factors, Inc. for application processing:
- Operating Authority
- Certificate of Insurance
- W-9 Form
- Customer List
- Articles of Incorporation or LLC Certificate
- Copy of Driver’s License
|
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or select Cancel to clear the form.
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843-678-3675, you can do so by clicking here.
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