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Client Profile

Print this page out, answer all questions completely, and fax to 804-739-3642. You can expect to receive up to four highly competitive offers within two business days. Please print neatly.

1. Legal name of business: ____________________________________________

Address: _____________________________________________________________

City: ___________________________________ State ______ Zip______________

Telephone: (______) _______-___________ Fax: (______) _______-___________

E-mail: ________________________________________________

2. Business Type (check one): ____Corporation ____Partnership ____Sole Proprietor

3. Date Established: _____________ 4. Avg. Monthly Sales: _______________

5. Federal Tax ID Number: _____________________

6. Does the company have any Federal or State taxes past due? ___Yes ___No

Describe your business in one sentence: _________________________________________

7. Name of owner: ____________________________________________________

Title: ________________________________________% of Ownership:__________

Address: _____________________________________________________________

City: ___________________________________ State ______ Zip______________

Telephone: (______) _______-___________

Social Security Number: ________-______-________

8. Name of owner: ____________________________________________________

Title: ________________________________________% of Ownership:__________

Address: _____________________________________________________________

City: ___________________________________ State ______ Zip______________

Telephone: (______) _______-___________

Social Security Number: ________-______-________

9. Name of your bank: ________________________________________

City: ___________________________________________________ State _________

10. Does the anyone have a security interest in the accounts receivable?

___Yes ___No

If yes to the above question:

Name of secured party: ________________________________

Telephone: (______) _______-____________

11. Please list your top three customers

Customer Name

Title: __________________________________________________________

City: ________________________________ State: ______ Zip: _________

Telephone: (______) _______-__________ Monthly Volume:___________

Customer Name

Title: __________________________________________________________

City: ________________________________ State: ______ Zip: _________

Telephone: (______) _______-__________ Monthly Volume:___________

Customer Name

Title: __________________________________________________________

City: ________________________________ State: ______ Zip: _________

Telephone: (______) _______-__________ Monthly Volume:___________

12. What is your monthly volume to be factored? ________________

The above statements are true and accurate to the best of my knowledge. This serves as my permission for the release of any information to participants in the FreightCash.com network regarding this application for the purpose of credit investigation. I hereby authorize any FreightCash.com participating factor to investigate the credit of all parties listed above.

13. Name of person submitting Client Profile: ________________________________

Title: _______________________________________________________

Signature: __________________________________________________

14. Tracking Number: 9999-9999

 

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