Online "Business Factoring" Assessment
Please take 10-15 minutes to fill out this online form to provide some basic company information.

With this information we can usually review your request to see if we can help you and give you a preliminary quote.

 

Only if you are satisfied with this quote will we ask you to complete a Factoring Application.

 

Submitting Office:
Exact Legal Name of Your Business:
Assumed/Fictitious Name:
Date Established (month/day/year):
Number of Employees:

Main Office Address

Street

City

 State Zip

Mailing Address   Same as above
Street
City State Zip
Phone Numbers
Tel:         Fax:       Cell:
Email:
Website:
Brief description of business:
Type of business:  
 
Sales
Last 12 months:  $
Projected next 12 months: $
Usual term of sale:   
Average receivable turn:     days
Average Invoice:  $
How did you learn of Cash Flow Network?

 

A/R Aging
Total $ 1-30 $ 31-60 $
61-90 $ 91 + $

About Your Invoices

Questions
Please answer "yes" or "no" to each of the following questions.  We will obtain
related details and/or documents later, if needed.
Yes No
1.  Are receivables currently factored or pledged?
2.  Have receivables ever been factored or pledged?
3.  Is inventory currently or has it ever been pledged?
4.  Are any sales made on a consignment, guaranteed sale, buy back, bill and hold, approval, or similar basis?
5.  Are any sales made to customers located outside the United States or Canada?
6.  Are any sales made to federal, state, or local governments?
7.  Are any sales made to customers from whom you purchase or to whom you owe money?
8.  Are there any returns, claims, disputes, offsets, credits, advance payments or any other situation that may reduce the balance of outstanding invoices?
9.  Are more than 25% of your sales to one customer?
10. Are any sales made to customers owned or controlled by anyone associated with your business?
11. Is your business currently operating profitably?
12. Has there been any major change in ownership or management during the last 12 months?
13. Is your business presently or has it ever been in bankruptcy?
14. Is your business considering filing bankruptcy?
15. Are any federal, state, and/or local taxes delinquent?
16. Is your business a party to any written or oral plan for payment of delinquent taxes?
17. Are any federal, state or local tax liens filed or threatened against your business?
18. Is your business a party in any pending litigation?
19. Is any litigation by or against your business threatened?
20. Are there any unsatisfied judgments against your business?
21. Are any licenses or permits required for your business to legally operate?
22. Is any major change in ownership or management anticipated during the next 12 months?
 

Top 5 Customers (plus % of business)
Customer 1
Customer Name:

%: 
City:

State: 
Customer 2
Customer Name:

%: 
City:

State: 
Customer 3
Customer Name:

%: 
City:

State: 
Customer 4
Customer Name:

%: 
City:

State: 
Customer 5
Customer Name:

%: 
City:

State: 
 
Decision maker within business
Name: 

Title: 

Phone:   Ext.
Email: 
 

Contact person concerning factoring Same as above
Name: 
Title: 
Phone:     Ext.
Email: 
 

Submitted by Same as above
Name:
Title:
Phone:      Ext.
Email: 

 

When may we contact you?
         OR   Date:    


Between and

Referring Office:

 

                   

 

A professional staff member from our factoring network will contact you within 24 hours of receiving the data.

 

 

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Cash Flow Network®     Mailing Address: POB 15397    Chesapeake  VA   23328

 Fax: 208-977-8999      Tel: 757-558-4677

 

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