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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)*
Address*
Street Address Address Line 2 City State ZIP Code
Company Phone*
Fax
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.
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 an Asset Based Loan agreement. In the event Centurion and Applicant fail to enter into an Asset Based Loan agreement, Centurion will file a termination statement.
Terms and Conditions*
- I agree to the above Terms and Conditions.
Company*
Name*
Title*
Name
This field is for validation purposes and should be left unchanged.

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