South Wynd Financial

P.O. Box 2113

Pinehurst, NC 28370

Phone:  (910) 690-8620    Fax:  (910) 295-2553

_______________________________________________________________________

 

FACTORING  APPLICATION

 

COMPANY:

 

      LEGAL NAME:    ____________________________________________________________

 

      ADDRESS:            ____________________________________________________________

 

                                     ____________________________________________________________

 

                                     ____________________________________________________________

 

      PHONE:  __________________________        FAX:  ________________________________

 

      CELL PHONE: ________________________________   E-MAIL:____________________________________

 

      CORPORATION:___   PARTNERSHIP:___  PROPRIETORSHIP:___  LIMITED LIABILITY CO.___  OTHER:____

 

      D/B/A - NAME:______________________________________________

 

      STATE  INCORPORATED /  REGISTERED:  ________________________

 

      FEDERAL  TAX  IDENTIFICATION  #:  ____________________________

 

OFFICERS  /  OWNERS  /  SHAREHOLDERS:

 

President:          Name-                      _________________________________

 

                          Home Address-        _________________________________

 

                                                            _________________________________

 

                              Home Phone-        _______________________

 

                              S/S #-                    _______________________    Driver’s License #- _____________________

 

                              Ownership            _________%

 

Vice President   Name-                      __________________________________

 

                              Ownership-           __________%

 

Secretary             Name-                     __________________________________

 

                               Ownership-          __________%

 

Treasurer            Name-                      __________________________________

 

                               Ownership-           __________%

 

BRIEF  DESCRIPTION  OF  BUSINESS:

 

______________________________________________________________________________________

 

______________________________________________________________________________________

 

 

FACTORING  APPLICATION

Page  2

 

CURRENT  LIENHOLDER:            _______________________________________________________________

 

COLLATERAL  DESCRIPTION:    _______________________________________________________________

 

_____________________________________________________________________________________________

 

                                                                                                                      

PAST DUE TAXES ?      YES _____     NO_____     IF YES- AMOUNT:  $__________________

 

    Explain- (Type, Reason, Payment Plan Approved, etc.):____________________________________________

 

__________________________________________________________________________________________

 

__________________________________________________________________________________________

 

LITIGATION?      YES _____     NO _____          Plaintiff: _____     Defendant: _____

 

    Explain-   (Reason, Party’s involved, $ in question, anticipated resolution):_____________________________

 

___________________________________________________________________________________________

 

___________________________________________________________________________________________

 

SALES  INFORMATION:

 

   Average Monthly Volume:       ________________________________________

 

   Terms:                                       ________________________________________

 

   Average Invoice Size:               ________________________________________

 

   Monthly Factoring Volume:     ________________________________________

 

DOCUMENTATION:

 

  • Financial Statements   -   Company:   FYE   and   YTD

                                                        Officers  /  Owners:   Current

 

  • Articles of Incorporation or Organization

 

  • Certificate of Good Standing  (Corporation)

 

  • D / B / A  Filing  (If Applicable)

 

  • Customer Listing  (Including Addresses, Phone/Fax, Contact Person)

 

  • Current  A/R  Aging

 

  • 941 Quarterly Payroll Tax Returns – Last 2 quarters w/ proof of payment

 

  • Transportation Companies:   ICC Authority,  DOT Motor Carrier Certificate,  Current Insurance Binder

                                                 

The undersigned hereby warrants that the information above is true and correct to the best of their knowledge.  Authorization is granted to South Wynd Financial to verify any information herein.  Further, authorization is granted to access information from any agency, public or private in order to investigate applicant, its owners, officers or employees.    

 

NAME:  _______________________________       DATE:  __________________________

 

TITLE:  _______________________________

 

(Revised 1/03)