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To expedite the processing of your application, please complete as many fields as possible. We employ industry-standard security measures to protect your data, but you may leave a field blank if you prefer and we will contact you for that information.

Company Information

Company Name
Trade Name
Address
City, State/Province, ZIP/PC
Telephone Number
FAX
Cellphone/Other
Date Established
Primary Contact
E-Mail Address
What Industry Are You In?
How Did You Hear About J D Factors?


Company Principals

Principal 1

Full Name
Social Security (US) or Social Insurance (Canada) #
Title
Telephone Number
Home Address
City, State/Province, ZIP/PC
Own   Rent

Principal 2

Full Name
Social Security (US) or Social Insurance (Canada) #
Title
Telephone Number
Home Address
City, State/Province, ZIP/PC
Own   Rent

Principal 3

Full Name
Social Security (US) or Social Insurance (Canada) #
Title
Telephone Number
Home Address
City, State/Province, ZIP/PC
Own   Rent

Accounts Receivable

Open Receivables $
Estimated Monthly Factoring Volume
Number of Active Customers
Terms of Sale (Net 30, COD, etc.)
Receivables Pledged? Yes   No
Ever Factored? Yes   No

Support Information

Insurance Agency
Agent/Contact Name
Telephone Number
Street Address
City, State/Province, ZIP/PC


Bank & Tax Information

Business Bank
Telephone Number
Bank Address
City, State/Province, ZIP/PC
Account Number
Date Account Established
Bank Officer
List Additional Accounts, Loans, and/or Lines of Credit
Number of Employees
Tax ID
List Tax Leins/Past Due


Electronic Signature

We have been told and do understand that the submission of an application for financing with J D Factors does not guarantee that J D Factors will factor or provide any financial services whatsoever.
We further have been told and do understand that approval to factor may come only after the Manager of J D Factors approves this application, and the accounts/invoices offered are approved in accordance with the terms of J D Factors Security Agreement.
We hereby affirm that the above statements are true and accurate to the best of my/our knowledge and belief. This serves as my/our permission for the release of any information regarding this application to J D Factors for the purpose of credit investigation.
The undersigned also hereby consent(s) to J D Factors collecting personal credit information, including personal credit report(s).

Please sign by typing your full name:



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