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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.
 
 US Client Application (English)

 US Client Application (Spanish)

Canadian Client Application (English)

Canadian Client Application (French)
   

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

Principals
1. Name*
Driver's License #
Home Street Address*
Own   Rent
City, State, Postal Code*
Home Phone Number*
SSN
Date of Birth
 
2. Name
Driver's License #
Home Street Address
Own   Rent
City, State, Postal Code
Home Phone Number
SSN
Date of Birth
 
3. Name
Driver's License #
Home Street Address
Own   Rent
City, Province, Postal Code
Home Phone Number
SSN
Date of Birth
 

Business Banking Information
Name of Bank*
Phone*
Fax*
Street Address*
City*
State*
Zip*
Account Number
Bank Contact*
 

Receivable Information
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 the manager of J D Factors approves said 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 information 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.

In lieu of signature, please check the box and type in your full name in the box below.
 

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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