21st Financial Solutions
APPLICATION FOR ACCOUNTS RECEIVABLE FACTORING
Fax to:  (815) 301-9077

Application Date: _____/_____/_____                                                        Date Company Established:_____/_____/_____
Company Information
Organization Type: 	 Proprietorship	 Partnership   	 Corporation	               State:________________
Company/Individual Name:____________________________________________________________________________  FictitiousBusinessName:_____________________________________________________________________________
Address: ___________________________________________City: ___________________ State: ____ Zip: __________
Phone: (       ) _______-__________   Fax: (       ) _______-__________  Fed Tax ID or SSN:________________________
Line of Business (Describe):___________________________________________________________________________
Business Category:   Service     Wholesale      Manufacturing   Est Monthly Factoring Volume:$______________
Number of Employees: _____	     Number of Independent Contractors: ______  Last 941 Filing______/_______/______
Est Avg ReceivableTurnover _______ Days   Avg Invoice Amount: $______________  Avg No of Invoices/Mo________
Have you factored in the past? (Y/N): ____  When: ________ Company________________________________________
Any UCC’s on file with A/R as Collateral? (Y/N): ____Company:______________________________________________
Any Tax Liens on file? (Y/N): ____ Amount: $___________________ Installment Agreement (Y/N): ______
Attorney: __________________________________		Phone: (       ) _______-__________
Accountant: ________________________________		Phone: (       ) _______-__________
Banking Information 
Bank: ________________________________________   Account Name:_______________________________________    
Account Number:______________________________    ABA/RoutingNo.(9Digits):______________________________ 
Address: _____________________________________    City: _________________________ State: ____  Zip: _______

Information about the Principals

 CEO/Pres: 	Name:______________________________Address:________________________________________
 Proprietor: 	City: ________________________State: _________ Zip: __________ Phone:____________________
 Partner:	Birthdate: ____/____/____ SSN: _____-____-_____ Drivers License: __________________________

 CFO/V.P.:     Name: ______________________________ Address: ______________________________________
 Secretary: 	City: ________________________State: _________ Zip: __________ Phone:___________________
 Partner:	Birthdate: ____/____/____ SSN: _____-____-_____ Drivers License: _________________________

__________________________________    ___________________________________     __________________________
                       (Signature)				 (Print/Type Name)			      (Title/Position)

__________________________________    ___________________________________     __________________________
           	       (Signature)			              (Print/Type Name)			      (Title/Position)