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INTERNATIONAL (NON-U.S.) COMPANIES: Click Here to APPLY YOUR CONTACT INFORMATION Company Name Type of Ownership Corporation S Corporation LLC Partnership Sole Proprietorship Other How Long in Business? City and State Your Name 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 Type of Business (Industry) Select Your Industry Accounting Business to Business Distribution Fashion-Apparel Freight Brokerage Law Manufacturer Medical / Healthcare Printing Security / PI Firms Service Staffing / Perm Placement Staffing / Temp Placement Staffing / Temp and Perm Telecommunications Transportation Trucking Wholesale Distribution Other

ABOUT YOUR ACCOUNTS RECEIVABLES Dollar Amount of Receivables Now Open Amount You Intend To Factor on Monthly Basis 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 If Factored in the Past
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