Factoring, Accounts Receivable Financing, Growth Capital Funding

COMPANY INFORMATION
Legal Business Name			Assumed/Fictitious or DBA

Date Established		Federal ID #	Number of Employees	Fiscal Year End

MAIN OFFICE ADDRESS			MAILING ADDRESS ( Same as main)
Street		State	Street	State

City		Zip Code	City	Zip Code

Telephone			Fax

Email			Website address

Brief Description of business			Business Legal Structure	If Corp., give year

			If Other, Specify	If Corp., select state

			How did you hear about American Factors Corporation?


Has there been a change of owners during the last 12 months or has there ever been a change of name of the business?
No	Yes	If yes, explain:

Name of Present Bank	Account Name	Account Number

Bank Address	City	State	Zip Code


Accountant's Name

Accountant's Address	City	State	Zip Code


TYPE OF BUSINESS

Check One:	Manufacturer	Wholesaler	Jobber	Retailer
	Other	Please specify:

ACCOUNTS RECEIVABLE INFORMATION		Billings -- Last 12 months	Billings -- Projected next 12 months
ACCOUNTS RECEIVABLE INFORMATION
Average # of Invoices/Month	Annual Bad Debt Write Off

Usual term of sale	Average receivable turn	Average Invoice Amount


A/R Aging, as of	Total$

01-30 Days -- $	31-60 Days -- $	61-90 Days -- $	91 + Days -- $

Top Ten Customers Comprise Approximately Percent of Total Yearly Sales

Number of Customers Anticipated to be Factored:
Average Number of Invoices that are anticipated to be Factored per month:

Are any Federal and/or State taxes past due?	No	Yes
Is this company now, or has it ever been, in Bankruptcy?	No	Yes
Has this company ever factored or pledged its receivables?	No	Yes
Are this company's receivables presently factored or pledged?	No	Yes
Has any company with whom an officer, owner or director has been associated within the
last ten (10) years factored or pledged its receivables?	No	Yes

If the answer to any of the previous five questions is "Yes", please give details, including names and addresses of party to whom receivables are or were factored or pledged and dates and name of company that pledged or factored its receivables:

INDIVIDUAL INFORMATION

Please list all OFFICERS and/or DIRECTORS of company:

	Last Name			Home Address
	First Name			City
	Middle Name			State	Zip
1	Home Phone			Social Security #
	Date of Birth			Place of Birth
	Drivers License #			State Issued
	Company Title
	Director	No	Yes	Percent of Ownership

	Last Name			Home Address
	First Name			City
	Middle Name			State	Zip
2	Home Phone			Social Security #
	Date of Birth			Place of Birth
	Drivers License #			State Issued
	Company Title
	Director	No	Yes	Percent of Ownership

	Last Name			Home Address
	First Name			City
	Middle Name			State	Zip
3	Home Phone			Social Security #
	Date of Birth			Place of Birth
	Drivers License #			State Issued
	Company Title
	Director	No	Yes	Percent of Ownership

DOCUMENTS ATTACHED

First page of Articles of Incorporation

Yes

DBA, Assumed, Fictitious or Trade Name Certificate

Yes

Most recent Accounts Receivable Aging Report

Yes

List of Customers proposed to be Factored

Yes

Most recent Profit & Loss Statement and Balance Sheet

Yes

DECLARATION

By submitting this form, I hereby certify that the information supplied in this Factoring Application and all forms and documents submitted to American Factors Corporation in connection herewith is true and correct to the best of my knowledge and belief.

I hereby authorize American Factors Corporation to investigate my/our financial responsibility and credit worthiness and will provide financial statements, tax returns, etc. as American Factors Corporation deems necessary. I/We hereby grant American Factors Corporation the right to procure any and all credit reports pertaining to any party to this application.

Submitted by	Title	Date

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