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Accounts Receivable Factoring Application

This form is also available as a download which can be faxed to 336-217-8155.
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Accounts Receivable Factoring Application
  Business Name:   
  Phone:  
  Fax:  
  Address:  
  Contact Person:  
  E-mail Address:
  Type of Business:   
  State:  
  Date Registered:   
  Tax I.D. #:   
  Are Taxes Current?    
  If no, how much is owed?   
  Officers  
  President:  
  SSN:  
   
  Vice President:  
  SSN:  
   
  Corp Secretary:  
  SSN:  
   
  Bank:  
  Account #:  
  Address:  
  Contact:  
  Phone:  
  Fax:  
   
List Major Clients Billed on a Regular Basis:
 
  Amt. to be Billed   Name   City, State   Pays in X Day
       
       
       
       
       
  Average Invoice Amount:  
  Approx. Monthly Amt. to be Financed:  
  Are receivables pledged elsewhere?  
  If yes, to whom?  

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P.O. Box 1755 1 North Jefferson Ave.
West Jefferson, NC 28694
Phone: 336-219-0105
Fax: 336-217-8155

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