1. Date: __________________
Prospective Factoring Client
Intake Checklist
Name of Company: __________________________________________________________
Address: ____________________________________________________
____________________________________________________
Client Contact Name and Title: ______________________________________________
Client Contact Phone Number(s) (____) ______ - __________ office
(____) ______ - __________ cell
Client Contact Email Address: _________________________________________________
Nature of Business: _____________________________________________________________
_________________________________________________________________________________
Use of Factoring Proceeds: _____________________________________________________
Check One: □ Seller of Goods or □ Provider of Service
Is sale pursuant to a Term Contract □ or a Purchase Order □?
Number of Customers: ____________________________
Annual Revenues: ____________________________ Gross Margin %: _______________
Current Debt: ____________________________
Are there any liens on Accounts Receivable? Yes □ No □
If yes, describe____________________________________________________________
____________________________________________________________________________
Taxes Current? Yes □ No □
If no, describe ___________________________________________________________________
__________________________________________________________________________________
Terms of Sale: □ 30 days □ 60 days □ Other_________________
□ Accounts Receivable Aging (Please attach – Excel Version Preferred)
□ Addresses for top 10 customers by sales volume (Please attach)
Referring Broker: _______________________________________________________
PLEASE BE SURE TO ATTACH RECENT AR AGING AND CUSTOMER ADDRESSES
When complete, return to chris.lehnes@gmail.com or fax to 203-516-9847