Accounts Receivable Financing Application

Email:

Company Name:

Address:

City:

State:

Zip:

Phone:

Fax.:

Legal Status:

Type of Business:

Date Established:

Federal ID No:

No. of Employees:

Does the company have any Federal or State taxes past due?

If Yes, has a lien been filed?

Bank Name and Branch:

Business Checking Account number:

Are the company's accounts receivable pledged as Collateral to any party?

II.  Owners, Officers or Partners:

Name and Title:

Home Address:

City:

State:

Zip:

Telephone No:

Driver's License No.:

Social Security No.:

Date of Birth:

Name and Title:

Home Address:

City:

State:

Zip:

Telephone No.:

Driver's License No.:

Social Security No.:

Date of Birth:

Name and Title:

Home Address:

City:

State:

Zip:

Telephone No.:

Driver's License No.:

Social Security No.:

Date of Birth:

III.  Schedule of Accounts

Customer Name:

Address:

City:

State:

Zip:

Phone:

Invoice No.:

Invoice Amount:

Customer Name:

Address:

City:

State:

Zip:

Phone:

Invoice No.:

Invoice Amount:

Customer Name:

Address:

City:

State:

Zip:

Phone:

Invoice No.:

Invoice Amount:

IV.  Marketing

Select BusinessFinance.com ETrucker.net Expeditersonline.com FedMarket.com Freightfinder.com GetLoaded.com Itruckers.net Joc.com Logisticsworld.com Mile.com Onvia.com Overdriveonline.com Thetrucker.com TruckDriver.net Truckstop.com Web Search Engine Yellow Pages Other

The above statements are true and accurate to the best of my information and belief. This serves as my permission for the release of any information to First Capital Funding Corporation (FCFC) and/or its assigned agents regarding this application for the purpose of credit investigation. I hereby authorize First Capital Funding Corporation to investigate the credit of all parties listed above.

Name and Title of person submitting this application: