Charting a path to Growth

J D Factors Security Agreement Application

Complete and submit the below Rapid On-Line application or click on one of the PDF applications to fill out and fax or e-mail. Click here to download Adobe Reader to view the PDF files.

US Client Application English Spanish
Canadian Client Application English French

Business Information

Fields marked with an * are required.

Business Name: * Company Legal Status: * Trade Names (DBA): Phone: * Fax: * Street Address: * City: * State: * Zip Code: * Country: Email Address: * Website Address: Type of Business: * Federal Tax I.D. Number: Number of Employees: Federal/State Taxes Past Due?:

Principals

Fields marked with an * are required.

First Principal Name: * Driver’s License Number: Home Phone Number: * Home Street Address: * Own: Rent: City, State, Postal Code: * SSN (Field is hidden): Date of Birth:

Second Principal Name: Driver’s License Number: Home Phone Number: Home Street Address: Own: Rent: City, State, Postal Code: SSN (Field is hidden): Date of Birth:

Third Principal Name: Driver’s License Number: Home Phone Number: Home Street Address: Own: Rent: City, State, Postal Code: SSN (Field is hidden): Date of Birth:

Business Banking Information

Fields marked with an * are required.

Name of Bank: * Phone: * Fax: * Street Address: * City: * State: * Zip Code: * Account Number (Field is hidden): Bank Contact: *

Receivable Information

Fields marked with an * are required.

Dollar Amount of Receivables Now Open: * Average Monthly Sales: * Approximate Number of Customers: * Terms of Sale: * Amount intended to factor on a monthly basis: * Maximum anticipated factoring volume: * How did you find out about J D Factors?: * Have you ever Factored/Financed before?: Yes: No:
Are your receivables currently pledged as collateral: Yes: No:

Principals Signatures

I/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.

I/We further have been told and do understand that approval to factor may come only after a Manager of J D Factors approves the application and the invoices/accounts offered are approved in accordance with the terms of J D Factors Security Agreement.

The above statements are true and accurate to the best of my knowledge and belief. By checking the box below and typing in my full name in the below space provided on this Rapid Line On-Line Application, this serves as my permission for the release of any information regarding this application to J D Factors for the purpose of credit investigation and I hereby consent to J D Factors collecting personal information including my personal credit report.

I further acknowledge that providing my SSN and other relevant account numbers on this form is optional for security and privacy concerns, but if I do not provide such information on this form that may delay the processing of the application and I will provide such information directly to the appropriate personal from J D Factors.

Fields marked with an * are required.

In lieu of a signature, please check this box: * And type in your full name in the box: * Anti-Spam Image:

Change Image Type text from image: *

Support Documentation

The following will be needed with your completed application. You will be contacted for them.

Articles of Incorporation
Customer List
Accounts Receivable Aging or Invoices to Factor
Bank Authorization Form
Tax Authorization Form
Copy of Trucking Authority and Insurance (Trucking firms only)

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