Secure Application

All information submitted here is secure on a High-Grade 256-bit encryption system.

Please note that all information provided will remain confidential and will not be disclosed to any third party.

General
Promotional Code:
Company Legal Name:
Company Address:
City/State/Zip:
County:
Email Address:
Telephone:
Fax:
Contact Person:
Title:
Corporation / Partnership / or Sole Proprietorship:
State Of Incorporation/Organization:
Federal ID#/Tax ID:
Bank:
Type of Business:
Years in Business:
Accounts Receivable
Revenue Last 12 Months:
Monthly Sales:
Current Account Receivable Balance:
Volume Expected To Be Factored (Monthly):
Customers To Be Factored:
Name:
% Of Sales:
Name:
% Of Sales:
Name:
% Of Sales:
Ownership
List all owners, partners, officers, etc.
Owner 1
Name:
Title:
Address:
City/State/Zip:
Home Telephone:
Social Security No.:
Date of Birth:
% Equity/No. Of Shares:
Drivers License Number:
State:
Owner 2
Name:
Title:
Address:
City/State/Zip:
Home Telephone:
Social Security No.:
Date of Birth:
% Equity/No. Of Shares:
Drivers License Number:
State:
Owner 3
Name:
Title:
Address:
City/State/Zip:
Home Telephone:
Social Security No.:
Date of Birth:
% Equity/No. Of Shares:
Drivers License Number:
State:
Owner 4
Name:
Title:
Address:
City/State/Zip:
Home Telephone:
Social Security No.:
Date of Birth:
% Equity/No. Of Shares:
Drivers License Number:
State:
Other Information
Secured Creditors (UCC Filings, Tax Liens, Etc.), If Any:
Give Details Of Any Contingent Liabilities, Such As Stand By Letters Of Credit, Lawsuits, Or Judgements Pending:
Have Your Income Tax Returns Ever Been Questioned By Any Governmental Agencies?
Taxes Due Or Past Due (If Any):
Have You Ever Filed For Bankruptcy Protection? If "yes", Give Details:

By submitting this application, the person(s) listed above agree to the following:

The statements contained herein and the documents attached hereto are true and accurate to the best of my (our) knowledge and belief. We authorize Prime Financial Group to obtain information regarding employment, bank accounts, and/or outstanding credit. We authorize any consumer or commercial credit reporting agency, business or person to provide any such information regarding us or our business as may be necessary in consideration of this application. This authorization will be valid for two (2) years from the date below. A photocopy of this authorization will be as valid as the original.

PF Funding, PF Funding LLC, and PF Funding Factoring