Factoring Application

*required fields

General Information

*Registered Entity Name:

Trade Name:	*Email Address:

*Address:	*City:	*State:	*Zip:

*Business Phone:	Business Fax:	County:

Type of Entity
	or Other:

Date Formed:		State of Incorporation:		*Federal Tax ID:

Operational Information

*MC#:	USDOT#:	*State:

Num. of Company Owned Trucks:		Num. Owner-Operators:

Num. Trailers:		Type(s) of Trailers:		*Type of Freight Hauled:

How Did You Hear About Trucker Funds?

Accounts Receivable Information

Total A/R Balance:	1-30 days:	31-45:	46-60:	60+:

Annual Sales Last Year:	*Avg. Sales This Year:	*Monthly Amount to be Factored:

Num. Active Customers:	Largest Customer:	% of Business:	Average Inv Size:

Have You Ever Factored Before?	Yes No
	If Yes, with whom?	When?

Are You Currently Factoring?	Yes No
	If Yes, with whom?	Contract End Date?

Ownership Information (Must Account for 100%)

*Owner Name:	Home Address:

*Social Security Num:	*Date of Birth:	Home Phone:	Cell Phone:

Title:	% of Owner Ship:

Owner Name:	Home Address:

Social Security Num:	Date of Birth:	Home Phone:	Cell Phone:

Title:	% of Owner Ship:

I HEREBY SUBSCRIBE AND AFFIRM, THAT ALL THE INFORMATION PROVIDED IS TRUE AND ACCURATE. ANCHOR FUNDING SERVICES, LLC ("ANCHOR") IS AUTHORIZED (AS DEEMED NECESSARY BY ANCHOR), TO VERIFY THE ACCURACY OF THE STATEMENTS AND INFORMATION PROVIDED AND TO CONDUCT CREDIT AND CRIMINAL INVESTIGATION, INCLUDING WITHOUT LIMITATION, OBTAINING ONE OR MORE CREDIT REPORTS FROM CREDIT BUREAUS.

ANY ADVERSE MATERIAL CHANGE TO THE FINANCIAL INFORMATION PREVIOUSLY SUPPLIED, MUST BE REPORTED WITHIN FIFTEEN (15) DAYS."

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