| Company Information |
| Legal Name of Company: | |
| Street Address 1: | |
| Street Address 2: | |
| City: | |
| State: | |
| Zip Code: | (5 digits) |
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| Contact Information |
| First Name: | |
| Last Name: | |
| Title: | |
| Phone: | |
| Fax: | |
| Email: | |
| Business Details |
| Type of Business Entity: | |
| Other Entity: | |
| How long have you been in business (years, months)?: | |
| Services or Products Provided: | |
| Does your company or your principles have any lawsuits?: | |
| Does your company or your principles owe any back taxes?: | |
| Does your company or your principles have any judgments?: | |
| Does your company or your principles have any current loans?: | |
| If yes, indicate loan amount: | |
| Does your company have any liens on receivables?: | |
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| Transaction Details |
| Average Monthly Sales Volume ($): | |
| Number of Active Customers: | |
| Average Time Between Billing and Collecting: | |
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Please list your five largest customers.
Your customers will not be contacted at this time. |
| Customer 1 Name: | |
| Address: | |
| City: | |
| State: | |
| Zip: | |
| Phone: | |
| Average Monthly Sales: | |
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| Customer 2 Name: | |
| Address: | |
| City: | |
| State: | |
| Zip: | |
| Phone: | |
| Average Monthly Sales | |
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| Customer 3 Name: | |
| Address: | |
| City: | |
| State: | |
| Zip: | |
| Phone: | |
| Average Monthly Sales: | |
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| Customer 4 Name: | |
| Address: | |
| City: | |
| State: | |
| Zip: | |
| Phone: | |
| Average Monthly Sales: | |
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| Customer 5 Name: | |
| Address: | |
| City: | |
| State: | |
| Zip: | |
| Phone: | |
| Average Monthly Sales: | |
| Other Information |
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