Accounts Receivable Funding Application

What type of cash flows are you interested in funding?

	General Accounts Receivable
	Medical Receivables
	Construction Receivables
	Government Receivables

THE COMPANY:

Legal Company Name:
DBA Name (if applicable):
Contact Name:
Street Address:
City:
State:	Zip:
Phone:	-- Ext. Fax: --
E-mail:	Website:

Company Structure:

	Corporation
	Not-For-Profit
	Partnership
	Other

Date Company was Established:
State of Incorporation:
Date of Incorporation:	Federal Tax ID/SSN:
Business Description:

If you are a medical practice, please complete the following:

Medicare UPIN #:	Are you Medicare Certified: Yes No
Are you a PIP Provider? Yes No

PRINCIPALS OF THE COMPANY:

Principal Name #1:
Title:
Address:
SSN Number:

Principal Name #2:
Title:
Address:
SSN Number:

Principal Name #3:
Title:
Address:
SSN Number:

What is your average monthly sales volume?

How much of your average monthly billing do you wish to factor? %

Have you ever factored your receivables? Yes No

If yes, with whom?

Total Accounts Receivable: $

Receivables > 90 days from invoice date: $

Does the Company or its Owners have any judgments or liens filed against them? Yes No

Does the Company or its Owners have any pending law suits against them? Yes No

Do the Company have any outstanding loans? Yes No

If yes, with whom? (Name of Financial Institution)

Balance Owed: $

Do you have any UCC Filings? Yes No If yes, with whom?

Are your receivables pledged as collateral? Yes No

PLEASE LIST THE CUSTOMER(S) YOUR FIRM PLANS TO FACTOR

(Medical Practices may skip this question)

1. Customer Name:
Average Monthly Sales:	$
City:
State:
Phone:	--

2. Customer Name:
Average Monthly Sales:	$
City:
State:
Phone:	--

3. Customer Name:
Average Monthly Sales:	$
City:
State:
Phone:	--

MISCELLANEOUS

How did you find us?

	Search Engine
	Print Ad
	Referral
	Other

Thank you for your interest in DGN Funding. A DGN consultant will get back to you within 24 hours of receipt of this application.

Questions about this application? Call: 1-877-865-7906 or Email: inquiries@dgnfunding.com