Factoring International - Online Form Our Factoring International Division has a network of offices in several countries. Please complete the short-form below. If we can factor in your country, the representative that handles your region will contact you shortly. Title With Company : Company : Full Name : Type of Ownership: Corporation S Corporation LLC Partnership Sole Proprietorship Other How Long in Business : Industry : Please Make Selection Business to Business Distribution Freight Brokerage Manufacturer Medical / Healthcare Printing Service Staffing / Perm Placement Staffing / Temp Placement Staffing / Temp & Perm Telecommunications Transportation Trucking Wholesale Distribution Other Telephone : Country : Email : State/Province: ABOUT ACCOUNTS RECEIVABLES Dollar Amount of Receivables Now Open Total Sales Last 12 Months Approximate Number of Customers Do You Sell on Terms of Net: 10 days 30 days 60 days 90 days Average Invoice Amount Are Your Accounts Receivables Pledged as Collateral?  No Yes If YES, to whom? ANTICIPATED MONTHLY FACTORING VOLUME Amount You Intend To Factor on Monthly Basis   Maximum Anticipated Annual Factoring Volume Are You Factoring Now or Factored in the past? Yes No If Factoring Now If Factored in the Past COMMENTS

Thank you for submitting the online form and for the opportunity to provide you with excellent factoring services. All requests are subject to final approval.