General Information

Business Address

Mailing Address

Contact Information

CorporationSole ProprietorPartnershipOther

Has there been a change of ownership in the last 12 months or a change of name of business?

YesNo

Does the business or any of the owners have any lawsuits pending at this time?

YesNo

Do any of the owners owe back taxes?

YesNo

List all businesses owned by any owners or their spouses in the last fifteen years. Also, please indicate whether the business is still in operation.

Receivable Information

Has this company ever factored or pledged its receivables?

YesNo

Are the company receivables presently factored or pledged?

YesNo

Has any company with whom an officer, owner, or director has been associated in the last ten (10) years factored or pledged its receivables?

YesNo

Are there any federal or state taxes past due?

YesNo

Are there any federal or state tax liens filed or pending?

YesNo

Has this company or its principals ever filed bankruptcy?

YesNo

If any of questions 15 through 20 were answered yes, please give all details including names and addresses of any party to whom receivables were factored or pledged. Include date and name of companies that factored your receivables. List on additional sheet if needed.

Please list all officers, owners, and/or directors of the company.

Home Address

Previous Address

Director

YesNo

Home Address

Previous Address

Director

YesNo

Financial Information

Instructions — please include all of the following when submitting your application below:

a. First page of Articles of Incorporation
b. DBA, assumed or trade name certificate
c. Most recent accounts receivable aging
d. Most recent accounts payable aging
e. Most recent profit and loss statement and balance sheet
f. Current customer listing with contact names, email addresses, telephone and fax numbers
g. Copy of driver's license

Please include a voided check with your application

First page of Articles of Incorporation

Email fileUpload file

Articles of Incorporation Upload

DBA, assumed or trade name certificate

Email fileUpload file

DBA Name Certificate upload

Most recent accounts payable aging

Email fileUpload file

Accounts Payable aging upload

Most recent accounts receivable aging

Email fileUpload file

Accounts receivable aging upload

Most recent profit and loss statement and balance sheet

Email fileUpload file

Profit and loss & balance sheet statement upload

Current customer listing with contact names, email addresses, telephone and fax numbers

Email fileUpload file

Current customer contact listing

Copy of Driver's License

Email fileUpload file

Upload Copy of Driver's License

Signature

I, individually and as an officer of the company, understand that American Receivable Corporation and its agent will rely on the information provided in this application in its evaluation of the company’s request. I hereby warrant and represent that this information and any other information the company or I may supply to American Receivable Corporation and its agent represents a correct, complete and accurate disclosure of all requested information on the company and does not omit any information, the omission of which would make the disclosed information misleading. The information also includes, whether requested or not, information that would materially impact the financial data included.

I hereby authorize American Receivable Corporation to share credit information about our company with its affiliates, subsidiaries, parent company, and all other parties permitted or required by law. I also authorize American Receivable Corporation and its agent to perform required due diligence including, but not limited to, reference calls and credit reporting services from sources they deem necessary to complete their review. I also understand that knowingly providing false or misleading information to American Receivable Corporation and its agent, or any of its affiliates or representatives may constitute as a criminal offense.

Date

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