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To expedite the processing of your application, please complete as many fields as possible. We employ industry-standard security measures to protect your data, but you may leave a field blank if you prefer and we will contact you for that information.

Company Information

Company Name

Trade Name

Address

City, State/Province, ZIP/PC

Telephone Number

FAX

Cellphone/Other

Date Established

Primary Contact

E-Mail Address

What Industry Are You In?

- Please Select - Trucking/Transportation Staffing Wholesale/Distribution Oilfield Services IT/Telecom Business Services Other

How Did You Hear About J D Factors?

Company Principals>

Principal 1

Full Name

Social Security (US) or Social Insurance (Canada) #

Title

E-Mail Address:

DOB

Ownership %

Telephone Number

Home Address

City, State/Province, ZIP/PC

Own   Rent

Principal 2

Full Name

Social Security (US) or Social Insurance (Canada) #

Title

E-Mail Address:

DOB

Ownership %

Telephone Number

Home Address

City, State/Province, ZIP/PC

Own   Rent

Principal 3

Full Name

Social Security (US) or Social Insurance (Canada) #

Title

E-Mail Address:

DOB

Ownership %

Telephone Number

Home Address

City, State/Province, ZIP/PC

Own   Rent

Accounts Receivable

Open Receivables $

Estimated Monthly Factoring Volume

Number of Active Customers

Terms of Sale (Net 30, COD, etc.)

Receivables Pledged? Yes   No
Ever Factored? Yes   No

Support Information

Insurance Agency

Agent/Contact Name

Telephone Number

Street Address

City, State/Province, ZIP/PC

Landlord/Management Company

Contact Name

Telephone Number

Street Address

City, State/Province, ZIP/PC

E-mail Address

Bank & Tax Information

Business Bank

Telephone Number

Bank Address

City, State/Province, ZIP/PC

Account Number

Date Account Established

Bank Officer

List Additional Accounts, Loans, and/or Lines of Credit

Number of Employees

Tax ID

List Tax Leins/Past Due

Electronic Signature

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.

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

We hereby affirm that the above statements are true and accurate to the best of my/our knowledge and belief. This serves as my/our permission for the release of any information regarding this application to J D Factors for the purpose of credit investigation.

The undersigned also hereby consent(s) to J D Factors collecting personal credit information, including personal credit report(s).

Please sign by typing your full name:

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