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Step 1 of 8 - Business Information

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Please type the phrase 'N/A' for all questions that do not apply.
Business Name (As listed on Articles of Incorporation or Partnership Agreement)*
Tax ID Number*
Address*
Street Address Address Line 2 City State ZIP Code
Company Phone*
Mobile Phone
Company Type*
List state of incorporation*
Doing business at more than one place? List all additional addresses
Email
Website

Please type the phrase 'N/A' for all questions that do not apply.
Indicate Industry Type*
- Manufacturing
- Wholesaler
- Distributor
- Service
- Other

Please type the phrase 'N/A' for all questions that do not apply.
Owner 1 Title*
Owners Name*
Home Phone*
Social Security Number*
Percentage of Company Owned*
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Is there a second owner?*
- Yes
- No
Owner 2 Title*
Owner 2's Name*
Home Phone*
Social Security Number*
Percentage of Company Owned*
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Is there a third owner?*
- Yes
- No
Owner 3 Title*
Owner 3's Name*
Home Phone*
Social Security Number*
Percentage of Company Owned*
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code

Please type the phrase 'N/A' for all questions that do not apply.
Current Receivable Amount Open*
Number of Accounts*
Terms of Sale*
Aging Current*
31-60 Days*
61-90 Days*
91-120 Days*
Over 120 days*
Total Sales Last 30 Days*
Total Sales Last 12 Months*

Please type the phrase 'N/A' for all questions that do not apply.
Customer 1
First Name*
Last Name*
Company Name*
Monthly Average Sales*
Average Invoice Size*
Phone*
Fax
Address*
Street Address Address Line 2 City State ZIP Code
Is there a second customer?*
- Yes
- No
Customer 2
First Name*
Last Name*
Company Name*
Monthly Average Sales*
Average Invoice Size*
Phone*
Fax
Address*
Street Address Address Line 2 City State ZIP Code
Is there a third customer?*
- Yes
- No
Customer 3
First Name*
Last Name*
Company Name*
Monthly Average Sales*
Average Invoice Size*
Phone*
Fax
Address*
Street Address Address Line 2 City State ZIP Code

Please type the phrase 'N/A' for all questions that do not apply.
Amount You Intend to Factor on a Monthly Basis
Have your receivables been financed or factored before?
- Yes
- No
Please explain:
Are your receivables currently being financed or factored?
- Yes
- No
Please explain:
Amount of Credit Losses Last Three (3) Years
Average Monthly Billing
Average Size Invoice
Largest
Smallest

How did you hear about Centurion?*
Please state*
Are you currently working with one of our Professionals?*
- Yes
- No
Please select:*

The undersigned individual(s) submitting this application who is either an officer, director, partner, member, owner of a sole proprietorship or shareholder of the Applicant, recognizing that his individual credit history may be a factor in the evaluation of the credit history of the Applicant, hereby consents to and authorizes the use of a consumer credit report by Centurion from time to time as may be needed in the credit evaluation.Applicant hereby authorizes Centurion to immediately file a financing statement covering all collateral of Applicant. The financing statement will become effective when (and if) Applicant and Centurion enter into a factoring agreement. In the event Centurion and Applicant fail to enter into a factoring agreement, Centurion will file a termination statement.
Terms and Conditions*
- I agree to the above Terms and Conditions.
Company*
Name*
Title*
Email
This field is for validation purposes and should be left unchanged.

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