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GENERAL INFORMATION Legal Name of Business Type of Ownership Corporation S Corporation LLC Partnership Sole Proprietorship Other City and State Your Name Your Position With The Company Attorney CEO CFO Controller COO CPA Director Executive VP Office Manager Owner President Sr. Vice President Vice President Assistant Vice President Other Select Email Phone Best Time To Contact You - am pm Type of Business (Industry) Select Your Industry Staffing / Perm Placement Staffing / Temp Placement Staffing / Temp and Perm Other

ABOUT ACCOUNTS RECEIVABLES Dollar Amount of Receivables Now Open Amount You Intend To Factor Monthly? Are Your Accounts Receivables Pledged as Collateral? No Yes If YES, to whom?

Are You Factoring Now or Factored in the past? Yes No If Factoring Now - With Whom? If Factored in the Past - With Whom?

HOW DID YOU HEAR ABOUT US? ------->	Please Select One Attorney Bank Other Lender Broker CPA CFG Client Alta Vista AOL Ask Jeeves Excite Google HotBot Jayde Lycos MSN Overture Yahoo YellowPages Other

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