AR Application Company InformationCompany NameDBAPhoneFaxAddressCityCountyStateZipEquipment Location(blank if same)CityStateCountyZipType of BusinessYears in Business# of employeesEmailFederal ID No.State of OrganizationSelectCorporationPartnershipProprietorshipLLCPrincipal/Partner/Officer% OwnedPrincipal/Partner/Office% OwnedAddressAddressCity/State/ZipSoc. Sec #City/State/ZipSoc. Sec #Total AssetsTotal Personal DebtTotal Personal DebtTotal AssetsEquity in CompanyNet IncomeEquity in CompanyNet IncomeTotal Personal DebtBank ReferencesBankContact PersonAccount #Phone #BankContact PersonAccount #Phone #Trade ReferencesSupplierContact PersonAccount #Phone #SupplierContact PersonAccount #Phone #Are any assets now assigned, pledged, or liened as collateral for loans?Accounts ReceivableYesNoIf so to whom?InventoryYesNoIf so to whom?EquipmentYesNoIf so to whom?The information in this Application provided by the Undersigned is true and correct in all respects and Firmco may rely upon the same for purposes of entering into an Accounts Receivable Financing Agreement with the Undersigned. Firmco is hereby authorized both now and in the future to (i) check the credit history of the Undersigned and the Undersigned’s business including bank accounts and personal credit reports and (ii) make available to Firmco’s corporate affiliates information relating to the Undersigned’s financial condition, including but not limited to reports prepared by credit agencies and information obtained from Undersigned’s creditors. Firmco is hereby authorized to file a UCC financing statement for the collateral contemplated fro this financing transaction. The undersigned warrants that He/She has authority to execute this Application and the Accounts Receivable Financing Agreement and to bind the Undersigned to the terms contained therein. The Undersigned authorizes all deposit and credit information to be released by telephone or fax. A photostat or facsimile copy of this authorization shall be valid as the original.SIGNATURETitleDate Submit Application