APPLICATION
ALL INFORMATION CONTAINED HEREIN SHALL BE CONSIDERED CONFIDENTIAL:
Date:
______________________________
Title: _______________________________
Legal Name:
______________________________
Phone: _______________________________
Operating Name: ______________________________
Fax: _______________________________
Company Contact: ______________________________ Cell: _______________________________
Address:
______________________________
Email: _______________________________
City, Prov., P.C. ______________________________________________________________________
Describe your company and the business you do: ______________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
How did you find out about us? ____________________________________________________________
Sole Proprietor
Partnership
LLC
Corporation
Corporation #:
Date established:
_______________ Years in present ownership: __________________________
Projected Annual Sales: _______________ Previous 12 Months Sales: __________________________
Projected Net Income: ________________ Previous 12 Months Net Income: _______________________
Have you worked with a factor before? Yes ____ No ____ Name of Company _______________________
Average volume to factor monthly
Average invoice size
$ ___________
$ ___________
Approximate number of Customers _________
Range of Invoice size ___________________
Please explain need in detail: _______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Revenue Canada Employer #:
Workers Compensation #:
How often does company remit payroll deductions? _____________________________________________
Type of Tax:
Amount in Arrears
or NIL
Payroll (source deductions) $ _____________
Income
$ _____________
G.S.T./ Federal
$ _____________
P.S.T. /State
$ _____________
Workers Compensation
$ _____________
Other
$ _____________
Arrangements to Repay:
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
PLEASE RETURN TO: (fax) 1-888-981-9611
or (email) info@lendmark.ca
PRINCIPALS OF THE COMPANY:
Officer Name:
___________________________________________________________________
Title:
___________________________________________________________________
SIN#:
___________________________________________________________________
Date of Birth:
___________________________________________________________________
Home Address:
___________________________________________________________________
Signing Authority: Yes_______
No _______
Percentage Owned: _____________________
Officer Name:
___________________________________________________________________
Title:
___________________________________________________________________
SIN#:
___________________________________________________________________
Date of Birth:
___________________________________________________________________
Home Address:
___________________________________________________________________
Signing Authority: Yes_______
No _______
Percentage Owned: _____________________
Officer Name:
___________________________________________________________________
Title:
___________________________________________________________________
SIN#:
___________________________________________________________________
Date of Birth:
___________________________________________________________________
Home Address:
___________________________________________________________________
Signing Authority: Yes_______
No _______
Percentage Owned: _____________________
THREE (3) SUPPLIER REFERENCES: (Companies who give you credit)
1. Name:
Telephone Number:
Business/Company:
Association with you:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
2. Name:
Telephone Number:
Business/Company:
Association with you:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
3. Name:
Telephone Number:
Business/Company:
Association with you:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Other Information:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
PLEASE RETURN TO: (fax) 1-888-981-9611 or
(email) info@lendmark.ca
BANKING INFORMATION
Name of Bank
Chequing Acct #
Bank Routing #
Branch
_________________________
Contact Person _________________________
Telephone
_________________________
Are the companys accounts receivables now pledged as security?
Yes ________ No ________
If yes, pledged with whom: _______________________________________________________________
Are other company assets pledged as security? Circle all that apply.: Accounts
Inventory
Equipment
Bank Loans:_______________________________ Collateral: ___________________________________
Have you ever had any personal or corporate Litigation/Judgements? Yes No (If Yes, please describe
on separate sheet)
Have you ever been convicted or found guilty of an offence under any law or are any charges now pending?
If yes, please attach full particulars on a separate signed and dated statement. Yes No
Have you ever gone insolvent? Yes
N
PROFESSIONAL REFERENCES
Name of Lawyer
___________________________
Telephone ____________________________
Name of Accountant ___________________________
Telephone ____________________________
The foregoing information is true and correct to the best of my knowledge and is given to induce The EBF Group Ltd. to consider
entering into a factoring agreement with this company. I hereby authorize The EBF Group Ltd. or its agents to verify and investigate any
or all of the foregoing statements, including but not limited to my/our credit worthiness and financial responsibility, in any way they may
choose. I/We grant The EBF Group Ltd. the right to procure any and all credit reports pertaining to any party listed in this application,
including, but not limited to, all principals of the applicant company.
AGREED AND CONSENTED TO:
Signature: _____________________________
Print Name: ___________________________
Title:
Date:
_____________________________
___________________________
PLEASE RETURN TO: (fax) 1-888-981-9611 or
(email) info@lendmark.ca
