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GENERAL BUSINESS INFORMATION |
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| Business
Name |
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| D/B/A
Name |
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| Address |
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| City |
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State
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Zip Code
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| Phone |
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Fax |
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| Email |
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Country |
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| Business
Type |
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Other |
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| State of
Incorporation |
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Year Started |
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| Other
Business Address |
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| City |
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State
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Zip Code
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| Product
or Type of Business |
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| Has the
company or any of its officers owners ever declared
bankruptcy before? |
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BUSINESS CREDIT REFERENCES |
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| Accountant |
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Phone |
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| Attorney |
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Phone |
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BANK AND SECURITY INFORMATION |
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| Bank
Name |
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Officer |
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| Address |
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| City |
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State
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Zip Code
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| Phone |
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| Check
all items for which your bank has a security interest: |
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Accounts
Receivable
Equipment
Inventory
Fixtures |
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| If any
other entity or person has a security interest in any of
your assets, please fill in the following: |
| Name |
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| Address |
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| City |
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State
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Zip Code
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| Purpose
of Security |
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| Are any
of your taxes past due?
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| If yes,
which type? |
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| Amount |
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RECEIVABLES INFORMATION |
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| Current
A/B Balance |
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Selling Terms |
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| Average
Monthly Sales |
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Average Amount |
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| List
Largest Customers and Average Monthly Receivables, address
and phone #: |
| 1 |
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| 2 |
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| 3 |
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| 4 |
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| 5 |
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Additional Customers
(if necessary) |
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COMPANY OFFICERS |
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| Name |
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Title |
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| Address |
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| City |
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State
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Zip Code
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| Phone |
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| % of
Ownership |
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| Date of
Birth |
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e.g. MM/DD/YYYY |
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| Have you
ever been arrested for, charged with or convicted of any
crime?
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| If yes,
please explain |
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STATEMENT OF ACCURACY
The statements made in and documents
attached to this application are true and accurate to the
best of my/our knowledge and belief.
AUTHORIZATION TO OBTAIN INFORMATION
I/We authorize MediPlant Funding(CFS)
to obtain whatever information regarding employment, bank
accounts, and/or outstanding credit (mortgage, auto,
personal, home improvement, charge cards, credit unions,
etc.) that CFS deems to be necessary in connection with this
application or in the course of review or collection of any
credit extended in reliance on this application. I/We
authorize and instruct any consumer credit agency,
commercial credit reporting agency, business or person to
compile and furnish to CFS any such information regarding us
or our business(es) as may be requested by CFS and agree
that such information, along with this application, shall
remain CFS’s property whether or not the application is
approved.
This authorization will be valid so long as applicant has an
outstanding balance with CFS. A photocopy of this
authorization will be as valid as the original. You
authorize MediPlant Funding to verify or check any of the
information given, including credit references and
employment and to obtain credit bureau reports as MediPlant
Funding deems necessary. |
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Principal Name |
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Principal Name |
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Principal Name |
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Principal Name |
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The
following information must be faxed to MediPlant to process
your application: |
1.
Current Accounts Receivable Aging
2. Articles of Incorporation or Other; D/B/A Filing
3. Current company financial statement (if available)
4. Proof of Federal Tax ID # (such as a tax coupon)
5. Photo Copy of driver’s license(s) for Company’s
principal(s)
6. Sample Copy of your business invoice
7. Current Accounts Payable Aging |
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Mediplant Funding Fax: (866)
931-0832 |
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(866) 867-9077