1 Transport Factoring, Inc. Application Form Legal Name Trade Name or DBA name Alternate Phone or Cell Current Physical Mailing Previous Physical (if at above address for less than 5 years) List complete name of any affiliate, subsidiary, holding or parent company. Select type of business Individual LLC Partnership Corporation Corporation Date Corporate Charter # Corporation State # of Employees Federal Tax ID Number or Social Security # Does company own real property? If doing business in more than one place, list additional address: Street Street Street Street
2 Transport Factoring, Inc. Total Number of Employees Total Number of Employees Tax Information Employees that are Full Time Total Number of Employees How often do you file 941 Payroll Taxes? Employees that are Part Time Total Number of Employees Weekly Monthly Quarterly Yearly Do you have any Federal or State Taxes past due? If, has a Federal or State tax lien been filed? If, please list type, quarter / year and amounts: BANKING INFORMATION Business Checking Bank Name Account # Name of Bank Officer Date Account Opened Business Loan Account - Name of Institution Account # Name of Loan Officer Amount of Loan Date Loan was established Collateral
3 Principals Name of President, Sole Proprietor or Senior Partner Title Home Social Security Number Date of Birth Drivers License # and State Name of President, Sole Proprietor or Senior Partner Title Home Social Security Number Date of Birth Drivers License # and State Name of President, Sole Proprietor or Senior Partner Title Home Social Security Number Date of Birth Drivers License # and State Insurance Agent Support Information Firm Name Name of Accountant - if any Firm Name Attorney Name - If any Firm Name
4 CREDIT INFORMATION List All Creditors / Prinipal Suppliers - (Attach additional sheets if necessary) Name Type Amount Acct # Contact Phone If, period of present lease Are you presently leasing your business space? Name of Landlord and/or Management Company Monthly Rental Amount RECEIVABLE INFORMATION What is the purpose of the funds to be generated from factoring?? Dollar Amount of receivables currently outstanding Average Monthly Sales Approximate number of customers Terms of Sales Amount you intend to factor on a monthly basis Maximum anticipated factoring volume
5 Have you factored before? If, with what company have/are you factoring? If, pledged to whom? Are your receivables pledged as collateral? How long do you intend to factor? Do you have any other commercial loans/leases outstanding? If, please list below - (attach additional sheets if necessary) List all customers whose invoices you initially want to factor. Attach additional sheets if necessary Company Contact Phone
6 GENERAL INFORMATION Any litigation pending against you, your company or shareholders? Any judgements outstanding? Any Federal and/or State Tax liens? (Attach Copy) Any UCC1 filings in any State? If, with whom? Contact IF you answered to any of the above questions, please explain fully below: What is your FMCSA MC Number? What is your Texas Motor Carrier Number? Of the trucks that you operate, how many do you own? What is your USDOT Number? How many trucks do you operate? How many do you lease? Are you involved in an "Agency Agreement" with another carrier or broker? If, with whom? (Provide copy of agreement) What type of products do you typically haul? Do you haul produce? Do you haul hazardous materials? If, what kind of hazardous materials? Are you current on all fuel and mileage taxes? If, list what is outstanding. Attach additional sheets if necessary.
7 I / We fully understand that the submission of an application for the purchase of Accounts Receivable by Transport Factoring, Inc. (hereinafter "Factor"), does not mean that factor will agree to factor or provide any services to Applicant whatsoever. I / We further fully understand that approval by Factor may come only after Factor approves this Application and all accounts/invoices offered in accordance with the terms of the Accounts Receivable Purchase & Security Agreement. The statements made herein and all information in all documents provided herewith are true and correct and Applicant understands that Factor intends to rely thereon in determining wheter to enter into a factor relationship. Applicant hereby authorizes Factor or any of its employees to examine its books and records and to discuss the affairs, accounts and finances of the Applicant with Applicant's officers, employees. Applicant hereby authorizes its suppliers, customers, accountants, creditors, attorneys, directors and employees to provide Factor any information about Applicant and its affairs, finances and accounts as Factor deems necessary to verify or investigate any or all of the foregoing statements. A copy of this authorization may be accepted as if it were an original. Applicant Company or Corporation Name By: (Print Name) Signature: Title Date:
8 DOCUMENTS Please attach copies of the following that apply to your company and check which are enclosed. Accounts Receivable Aging Accounts Payable Aging Customer List with / Phone and current credit limits. Company Financial Statements - current month and past 3 years if available Personal financial statements of principals OR copy of last 2 years tax returns Assumed name certificate / Fictitious Name filing Sample of Company's Invoices, Bills of Lading and Credit Memos Copy of Agreement with any other Factor. IF PARTNERSHIP - Partnership Agreement Required for Corporations Copy of Articles of Incorporation Copy of Corporate By-Laws Personal financial statements of Principals Required for Carriers Copy of Texas Motor Carrier Authority and Insurance Cab Card Listing Copy of Federal Operating Authority Copy of Single State Registration Copy of Insurance Copy of Lease Agreement Copy of Agency Agreement Please provide us with any additional information or comments:
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