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Application

The fields marked with * are mandatory.

Information Request Form

Company Information

* Business Name:
  Trade Name:
  (if different)
*Physical Address:
  Mailing or Business Address:
  (if different)
* Phone:
  Cell:
  Fax:
* Email:
  Please indicate what type of business you are:
 
Sole Proprietorship - Individually owned
Corporation
Partnership
Public Utility
Limited Liability Company (LLC)
Other
 

Primary Owners / Officers / Shareholders

  Owner 1

* Name:
* Address:
* City:
* State:
* Zip:
* SSN:
* Title:
* Ownership%:
* Phone:
  (1-234-567-8910)
 

  Owner 2 (if applicable)

  Name:
  Address:
  City:
  State:
  Zip:
  SSN:
  Title:
  Ownership%:
  Phone:
  (1-234-567-8910)
 

  Owner 3 (if applicable)

  Name:
  Address:
  City:
  State:
  Zip:
  SSN:
  Title:
  Ownership%:
  Phone:
  (1-234-567-8910)
 

  Owner 4 (if applicable)

  Name:
  Address:
  City:
  State:
  Zip:
  SSN:
  Title:
  Ownership%:
  Phone:
  (1-234-567-8910)
 
  What is the primary industry you do business in?
 
Transportation   Real Estate
Manufacturing   Professional Services
Employment Staffing   Health Care
Construction   Retail / Wholesale
Other  
 
  Dun & Bradstreet No:
 
  yes no
Listed
Rated
 
  Have you ever filed for bankruptcy or are you currently operating under bankruptcy proceedings?
 
Yes   No
  If yes please explain:
* How many years have you been in business?
 
  This Section is for Transportation Companies Only
  Are you a carrier, broker or both?
  Authority:
  (Check each that applies)
    MC/DOT No.(s):
Common
Contract
Broker
  If you broker loads, do you intend to factor brokered loads hauled by other carriers?
 
Yes   No
  Have you ever operated under any other name or MC/DOT number? If so, please provide the name, address and MC/DOT number:
 
 

Business Bank Information

*Bank Name:
*Address:
*City:
*State:
*Zip:
*Phone:
*Account #:
*Routing #:
*Account Type:
*Contact:
 

Trade References

  Reference 1
*Name:
*Address:
*City:
*State:
*Zip:
*Phone:
*Contact:
  Account #:
 
  Reference 2
*Name:
*Address:
*City:
*State:
*Zip:
*Phone:
*Contact:
  Account #:
 

Factoring

  Have you ever factored before? Yes   No
  If yes, with who?
* What are your total average monthly sales? $
* What is the estimated monthly dollar amount you plan to factor? $
 

Responsibility

I (we) hereby certify that the information contained in this application is complete and accurate. This credit information has been furnished with the understanding that it is to be used to determine the amount of credit to be established. Furthermore, I (we) hereby authorize the financial institutions and trade references listed above to release necessary information to Advanced Commercial Capital, Inc. in order to verify the information contained herein. Applicant's typed name attests responsibility and willingness to factor in accordance with Advanced Commercial Capital's terms.

* Type Your Name Here
* Your Title
   Date 22-Sep-2017
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