1.  Legal name of company (as shown on the Articles of Incorporation or Partnership Agreement)
 
    
 
     Address
 
     City State Zip Code   State of Incorporation 
 
     Phone Number   Fax Number
    
     Contact/Position    Email:
 
 2.  Your business is a:  Corporation  LLC   Proprietorship  Partnership  Other
 
 3.  How long have you been in business?   Federal I.D. #
 
 4.  Describe your business
 
 5.  What is your average monthly billing?
 
 6.  How much of your average monthly billing do you wish to factor?
 
 7.  What is the average size of your invoices?   Largest   Smallest
 
 8.  Are any or your receivables progress billings? (In other words, do you bill in “as-completed” phases for larger products?)
Yes  No
 
 9.  List most important major customers (customers are not contacted at this time):
 
          Company Name                                                   Street Address, City, State and Phone Number
 
1. 
 
2. 
 
3. 
 
4. 
 
5. 
 
10. Do you have any outstanding loans? Yes  No
 
11. Are receivables pledged as collateral? Yes  No
 
12. Name of Institution(s)   Loan Amount and Terms
 
13. Are your federal, state, and payroll taxes current?  Yes  No
     
      If not, please list amounts owed and what for:
      Federal balance owed    State balance owed

      Any liens placed?  Yes  No    
      Do you have a payment plan?  Yes  No         Monthly payment

      Are you currently involved in any type of litigation or lawsuit  Yes  No
     
      If yes, please describe                                                                                                                                
 
14. Company’s Attorney    Phone Number
     
15. Company’s Accountant    Phone Number
 
16. Have you previously financed/factored your accounts receivable?  Yes  No
 
17. If yes, what is the name of the previous finance company?
 
I attest that the statements in this application for financing are true and correct to the best of my knowledge.  I authorize Baker Capital Solutions, LLC and/or its representatives to verify any or all of these statements in any way it may choose and the right to procure all credit reports of the principals of the applicant company.
 
Check Here If You Agree To The Above:  I Agree 
 
Your Name: 
 
Your Title: