FACTORING APPLICATION Dash Point Financial Asterisks (*) indicate required fields.   COMPANY INFORMATION Company * Contact first name * Contact last name * Title * Company street address * City, ST, Zip * Company mailing address (if different) Mailing City, ST, Zip Office Phone * Fax Cell Email * Web Site Industry/Business Description * Your business type * S Corporation C Corporation LLC Partnership Sole Proprietor State of corporate registration - - Choose One - - Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming FEIN # * All names company has used or registered * OWNERSHIP INFORMATION Current Owner's First, Middle & Last Names * Owner's Maiden name Owner's Date of Birth * Owner's Home Address * Owners Home City, State, Zip * Social Security # Last 4 digits * % Ownership * Other Owners Name/s Other Owners % Ownership Ownership change in last year? * No Yes Previous owner name/s (if Yes) FACTORING INFORMATION Expected monthly factoring volume to start * Avg. invoice size ($ amount) * # of customers to factor * How long in business * Factored before? * No Yes Previous factoring company name BILLING INFORMATION Total billings last 30 days * Total billings last 12 months * Annual bad debt write off * Total current receivables * Current (0-30 days) * 31-60 days * 61-90 days * 91+ days * Describe your billing process from invoicing to collection * Do you: Send monthly billing statements? * No Yes Utilize progressive billing (bill in stages)? * No Yes Bill prior to completion? * No Yes Warranty or guarantee any sales? * No Yes CUSTOMER INFORMATION List up to 4 customers to factor (this is for credit research only; they will NOT be contacted). Be sure company names are spelled correctly. INCLUDE FOR EACH: Company, Address, City, ST, Phone, Approx. monthly volume, Usual # of days to pay 1st Customer * 2nd Customer 3rd Customer 4th Customer TAX INFORMATION Are your: State taxes current * No Yes Federal & payroll taxes current * No Yes If No please describe Tax liens or other liens * No Yes OTHER INFORMATION Does your business, or do you personally, have any: Bank loans or lines of credit * No Yes Unresolved collections against you or your company * No Yes Pending litigation, or unsatisfied existing liens or judgments * No Yes Felonies or misdemeanors * No Yes If Yes to any please describe Ever declared personal or business bankruptcy? * No Yes If Yes give chapter (7,11,13) & year/s of filings REFERRAL INFORMATION How did you find us? * Broker Consultant Other Factor Web Search Friend/Colleague FactorFind Other Name of person or company who referred you Name of person submitting this form * Your phone number * The foregoing information is provided by an authorized company representative or broker consultant, and is true and correct to the best of my knowledge. Upon clicking the Submit button, Dash Point Financial Services or its agents are authorized to verify and investigate any or all of the foregoing information.