Online Factoring

Applicant (Legal Business Name)*
Street Address*
City *
State*		Zip*
County
Telephone*
Cell phone
Fax
Email Address *
How did you hear about Merchant Money?*
If "Other" or "referred by" please provide additional information

Business Information

Federal Tax ID #
Date business established
State of Organization
Legal form of business (pick one)
If your business is a sole proprietorship or partnership, list the legal names of the owners.
If your business is a Corporation or LLC, what is your Charter Number?
Describe your primary business activity
Does Applicant or any of its owners, partners or shareholders operate or have ownership in any other businesses or trade names?	yes no
If so, please list
Has Applicant or any owner ever filed bankruptcy?	yes no
If so, please give details
Have any liens or judgments been filed against Applicant or any owner?	yes no
If so, please describe
Is there any actual or proposed litigation relating to the Applicant or any owner?	yes no
If so, provide details
Is Applicant current on all Federal and State tax related payments and filings?	yes no
If not, please provide details
Have any of applicant’s owners, shareholders, or partners ever been convicted of a felony?	yes no
If so, please provide details

Ownership / Management

Name
Address
City
State
Zip
	If at current address less than 3 years, please list previous address
Address
City
State
Zip
Phone
Cell Phone
Title
% Ownership
Date of Birth
Social Security No.

Name
Address
City
State
Zip
	If at current address less than 3 years, please list previous address
Address
City
State
Zip
Phone
Cell Phone
Title
% Ownership
Date of Birth
Social Security No.

Name
Address
City
State
Zip
	If at current address less than 3 years, please list previous address
Address
City
State
Zip
Phone
Cell Phone
Title
% Ownership
Date of Birth
Social Security No.

Name
Address
City
State
Zip
	If at current address less than 3 years, please list previous address
Address
City
State
Zip
Phone
Cell Phone
Title
% Ownership
Date of Birth
Social Security No.

Accounts Receivable Information

1. What is your accounts receivable balance?
Approximately how much did you invoice in the past 30 days?
3. Approximately how much did you invoice in the past 12 months?
4. Do Applicant’s receivables serve as collateral for any purpose?	yes no
If so, with whom?
5. Approximately how many active customers do you have?
6. What is your average invoice size?
7. Is Applicant or any owner related to any customer account?	yes no
If yes, list names
8. Does Applicant sell any goods or services to customers from which Applicant purchases goods or services?	yes no
If yes, list names
9. Has applicant (or an owner of applicant) ever factored its receivables before?	yes no
If yes, with what factoring company?

Customers

List top 5 Customers in order of monthly billing amount.

Customer	Address	Contact	Telephone	Avg. Sales/Mo.

Banking Information

1. Bank Name
2. City and State
3. Account number
4. Routing number
5. Does the Applicant have any outstanding Secured loans or leases?	yes no

Secured Creditors

List Secured Transactions and Leases (Credits, Loans and Leases)

Lender's Name	Contact Telephone	Balance	Description of Collateral

Vendor References

List 3 Primary Vendors

Vendor Name	Contact	Contact Telephone	Balance	Credit Limit

The undersigned understands that all information provided in connection with this form is for the purpose of aiding Merchant Money Holdings LP (Merchant Money) in its consideration of entering into a contractual relationship with the Applicant. The above responses are true and accurate to the best of my knowledge and belief, and Charter Capital may rely upon the same for all of its purposes. Furthermore, any party referenced in this form may rely upon this statement as authorization from Applicant to freely respond to any inquires made by Charter Capital regarding Applicant.

* 1. Applicant
* 2. Submitted by
* 3. Title
* 4. Please type your initials here to sign this document
* 5. Date (mm/dd/yyyy)