NCFI -

Nationwide Capital Funding Application Form
Client Information
(* - Required Field)
All information provided will be strictly confidential

GENERAL:

*Legal Company Name

*Date Established

Registered Trade Name (DBA if different)

Employer Identification Number (EIN)

*Physical Address

Mailing Address

*City *State *Zip

County

*Phone Fax

*Contact
Title

Complete name of any and all affililiates, subsidiaries, divisions, holding or parent company

*Type of Company   Corp Partnership Sole Proprietor LLC

*State of Incorporation Date of Incorporation

Outstanding Taxes Lien Filed? Yes No

Existing Judgements Existing Liens

Bankruptcy Filed?   Yes No   If yes, when?

*Has the Applicant or any Principles of the company ever been convicted of a felony?   Yes No   If yes, where?

SALES/RECEIVABLES:

*Monthly Sales Volume

Terms of Sale *Number of Clients

# Invoices/Month

*Current A/R

*Volume to Factor & Frequency

Weekly Monthly

*Legal Company Name
*Date Established
Registered Trade Name (DBA if different)
Employer Identification Number (EIN)
*Physical Address
Mailing Address
*City	State Zip
County
*Phone	Fax
*Contact	Title
Complete name of any and all affililiates, subsidiaries, divisions, holding or parent company
*Type of Company	Corp Partnership Sole Proprietor LLC
*State of Incorporation	Date of Incorporation
Outstanding Taxes	Lien Filed? Yes No
Existing Judgements	Existing Liens
Bankruptcy Filed?	Yes No If yes, when?
*Has the Applicant or any Principles of the company ever been convicted of a felony?	Yes No If yes, where?

*Monthly Sales Volume	Terms of Sale Number of Clients*
# Invoices/Month	*Current A/R
*Volume to Factor & Frequency	Weekly Monthly