Factoring Application

Please complete the form below and click "Submit" to apply for credit through OmniFunding.

For your convenience, we also offer a downloadable version that you may fax back to us. This version requires that you have the Adobe Acrobat Reader application installed on you computer.

APPLICATION FOR ACCOUNTS RECEIVABLE FACTORING
Items marked with an asterisk (*) are required.
--------------------Company Information--------------------
*Company / Individual Name:
Ficticious Business Name:
*Address: Street:
*City:		*State:
*Zip:
*Phone:		Fax:
*Fed Tax ID or SSN:
*Date Company Established:
*Organization Type:	Choose... Corporation Partnership Sole Proprietor LLC / LP / LC			*State:
*Line of Business (describe):
*Business Category:	Service
	Wholesale
	Manufacturing
	Other
*Est. Monthly Factoring Volume:
*Number of Employees:		*Number of Ind. Contractors:
*Last 941 Filing:
*Est. Avg. Receivable Turnover (days):
*Avg. Invoice Amount:
*Avg. Number of Invoices per Month:
*Have you factored in the past?	Yes     No
When:		Company:
*Any UCCs on file with A/R as collateral?	Yes     No
Company:
*Any tax leins on file?	Yes     No
Amount:		Installment Agreement?		Yes     No
Attorney:
Attorney's Phone:
Accountant:
Accountant's Phone:
--------------------Banking Information--------------------
*Bank Name:
*Bank Address: Street:
*City:		*State:
*Zip:
*Account Name:
*Account #:		*ABA/Rounting #: (9 digits)
--------------------Information About the Principals--------------------
*Principal 1:	CEO/President     Proprietor     Partner
*Name:
*Address: Street:
*City:		*State:
*Zip:
*Phone:		*Birthdate:
*SSN:		*Driver License:
Principal 2:	CFO/VP     Secretary     Partner
Name:
Address: Street:
City:		State:
Zip:
Phone:		Birthdate:
SSN:		Driver License:
YES, I authorize Omni Funding or assigns to contact you for verbal ratings on my bank accounts or trade references. If policy is no verbal ratings, Omni funding will fax an information release to complete and fax back. By signing above, the individual as principle of and/or guarantor for the credit applicant authorizes Omni Funding, its designee, assigns or potential assigns, the use of consumer credit reports in considering this application, and from time to time as may be needed to: update, renewal, or extension of applicant credit, and for the collection of any resultant accounts. A fax or photocopy of this authorization shall be valid as the original. Please fax to: (801) 566-7458.