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Business Name   Date Established
Street Address   County
City/State/Zip   Phone
Email Address   Fax
Corporation LLC Partnership Sole Proprietor
Description of Business
         
Federal ID #   Number of Employees
         
Any Federal or State Taxes Past Due?
Yes No
  If Yes: Type and Amount:
         
Has a Lien been filed?
Yes No
     
         
Are receivables pledged as collateral?
Yes No
  If Yes:To whom?
         
Officers, Owners or Partners
         
Name and Title #1   % Owned
Driver's License #      
         
Home Address   City/State/Zip
 
Rent Own
     
         
Home Phone   Social Security #
      Date of Birth
         
Name and Title #2   % Owned
Driver's License #      
         
Home Address   City/State/Zip
 
Rent Own
     
         
Home Phone   Social Security #
      Date of Birth
         
Business Banking Information
         
Name of Bank   Date Account Opened
Bank Address   Phone
Checking Account Number   Name of Bank Officer
Any Commercial Loans Outstanding?
Yes No
  Loan Account #
Loan Officer   Amount
Collateral      
         
Miscellaneous Information
         
Anticipated Factoring Volume      
How Did You Learn About Us?      

 

        

Allegiant Business Finance | 600 University Street, Suite 2800, Seattle WA 98101
Phone: (206) 625-0898 | Fax: (206) 625-1330 | info@allegiant1.com
  
 
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