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Client Profile Form
EXACT LEGAL NAME :
CITY,STATE,ZIP or CITY, PROVINCE,POSTAL CODE :
CONTACT NAME :
STATE or PROVINCE OF REGISTRATION :
D/B/A (IF APPLIC) :
EMAIL ADDRESS :
TAX ID # (MANDATORY) :
BUSINESS DESCRIPTION :
Officers - Business Information
VICE PRES. :
Receivable & Contract Information
AVERAGE SIZE OF INVOICE :
ESTIMATED MONTHLY BILLING AMOUNT?
ARE COMPANY TAXES UP TO DATE?
IF NO, HOW MUCH DUE?
PAYMENT PLAN IN PLACE?
ARE RECEIVABLES PLEDGED AS SECURITY ELSEWHERE?
IF YES, WITH WHOM?
The Undersigned warrants that the above information is true and correct. All information and documentation will be held in the strictest confidence by our company and our Funding Source partners and will not be used for any other purpose other than to determine eligibility for funding.