12500 S Cicero Ave

Alsip, IL 60803
708-844-7920
[email protected]

APPLICATION FOR FACTORING

GENERAL BUSINESS INFO

Legal Business Name:

Assumed name(s)/DBA: Federal Tax ID: Phone: Email:

Address: City: State: Zip code:

Mailing Address (if different): City: State: Zip code:

MC: US DOT: State of Incorporation: County:

Business Type: Corp LLC Partnership Proprietor

Number of Company Trucks: Trailers: Number of Owner
Owned Operator Trucks:

OWNERS/SHAREHOLDERS:
Full Name: Title: Ownership %:

Phone: Cell: Email:

DL#: State: Expiration: SS#: DOB:

Home Address: City: State: Zip code:

Full Name: Title: Ownership %:

Phone Cell: Email:

DL#: State: Expiration: SS#: DOB:

Home Address: City: State: Zip code:

Rev: 02/23 1 of 3
INSURANCE:
Insurance Company Name: Expiration Date:

Agent: Phone:

FINANCIAL:
Bank Name:

Phone: Account Number:

FACTORING:
Are you currently Factoring your accounts receivable? If yes, please provide a Yes No
copy of your Factoring Agreement and complete the section below.
Factoring Company Name:

Contact Person: Phone:

LEGAL:
Are there any delinquent federal or state taxes? Yes No
Has the Company ever filed for bankruptcy or had a petition in bankruptcy Yes No
filed against the Company.
Is the Company engaged in, or threatened with any litigation? Yes No
Do you currently have a loan with the Small Business Administration (SBA)? Yes No

PLEASE PROVIDE:
1. Articles of Incorporation/Organization and any DBA filings
2. DOT Letter of Authority
3. Internal Revenue Taxpayer ID Letter
4. Accounts Receivable Detail Aging Report
5. Voided Check/Bank Statement
6. Certificate of Insurance
7. Driver’s License (All Owners/Shareholders)
8. W9 Form

How did you inquire about our services?

_______________________________________________________________________________

Rev: 02/23 2 of 3
 UCC FINANCING STATEMENTS:

The undersigned hereby authorizes Pro Funding, Inc. (“Pro Funding”) to pre-file Uniform
Commercial Code ("UCC") financing statements in any jurisdiction naming the company for which
this application is being submitted (the “Applicant”) as Debtor and identifying all assets of
Applicant as collateral to perfect its security interest in the assets of Applicant in anticipation of
Pro Funding extending financial accommodations to the Company pursuant to agreements being
negotiated in which Pro Funding will be granted a security interest in all assets of Applicant.

STATEMENT OF ACCURACY:

The undersigned certifies that this Application and the information contained herein is submitted for
the purpose of procuring, establishing, and maintaining an accounts receivable factoring facility for the
business or commercial purposes only and the proceeds will not be used for any personal, family or
household purposes. By signing and submitting this Application, the undersigned certifies that the
information contained herein, and all forms and documents provided in connection herewith, are true
and correct, and that the undersigned is duly authorized by the company to submit the application. The
undersigned acknowledges and agrees that the information provided in this Application ant the forms
and documents submitted to Pro Funding, Inc. will be relied upon by Pro Funding, Inc. in extending a
factoring facility. The undersigned expressly authorize consumer reporting agencies and other persons
to furnish credit information to Pro Funding, Inc. on all individuals and businesses whose name appears
on the application. The undersigned agree Pro Funding Inc. may receive and exchange credit
information and update such information as appropriate during the term of the factoring relationship.

_______________________________________
Name

_______________________________________
Title

_______________________________________
Signature

_______________________________________
Date

Rev: 02/23 3 of 3