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14. What is the purpose of the funds to be generated from factoring?__________________________
_________________________________________________________________________________
15. Have you factored before? Yes____No____ If yes with what company____________________
Have you ever applied for factoring with any other company? Yes______No_____
If yes with what company(s) ______________________________________________
16. Are receivables/inventory/equipment pledged as collateral? Yes____ No____
If yes, to which lender? Name_____________ Contact____________Phone number___________
17. Any litigation pending against the client or owner/officer? Yes____No____
. Any judgements outstanding?(attach a copy) Yes____No____
Any Federal or State Tax Liens?(attach a copy) Yes____No____
Has any owner/officer ever been convicted of a felony? Yes____No____
Has any owner/officer ever been involved in a bankruptcy? Yes____No____
If a yes answer to any of the above questions please explain fully in the space provided below.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
18. Please attach the following to this application form:
-Copies of Articles of Incorporation and By Laws
-Copy of Fictitious Name Filing (if applicable)
-Copy of Partnership Agreement (if applicable)
-Financial statements
-Schedule of aged accounts receivable
-Copy of 941 withholding tax filings & proof of payment
I/we fully understand that the submission of an application for the purchase of accounts receivable by Brookridge Funding Corp., (hereinafter "Factor") does not mean that Factor will factor or provide any services to Applicant
whatsoever.
I/we fully understand that approval by Factor may come only after Factor approves the application and all
accounts/invoices offered in accordance with the terms of the Accounts Receivable Purchase Agreement.
The statements made herein and all information in all documents provided herewith are true and correct and the
Applicant understands that the Factor intends to rely thereon in determining whether to enter into a factoring
relationship.
Applicant hereby authorizes its suppliers, customers, accountants, attornies, employees and credit agencies to
provide Factor any information about Applicant and its affairs, finances and accounts as Factor or its employees
may request. A copy of this authorization may be accepted as if it were an original.
Applicant: ____________________________________________________
By: _____________________________________________________
(Signature)
Print Name: ___________________________________________________
Title: ______________________________
Date: ______________________________
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