Online Application

BUSINESS INFORMATION      
Company Name:
 DBA:
Current Street Address:
 Apt./Suite:
City:
 State:
 County:
 Zip Code:
Business Phone:
 Business Fax:
  
Email Address:
 Website URL:
  
Date Formed:

 State of Formation:
 Federal Tax I.D.:
Entity Type: C Corportation S Corportation Partnership LLC Sole Proprietor
Brief Business Description:
How did you hear about Keystone Capital Funding?:

 

PERSONAL INFORMATION
Owner First Name:

 Last Name:
 Title:
% Ownership:

 Home Street Address:
  
City: State: Zip:
Phone: - Cell: -  
Fax: - Email Address:  
Date of Birth: Social Security Number:  

 

OTHER OWNERS/PARTNERS
Owner First Name:

 Last Name:
 Title:
% Ownership:

 Home Street Address:
  
City: State: Zip:
Phone: - Cell: -  
Fax: - Email Address:  
Date of Birth: Social Security Number:  

If there are additional owners/partners, please list on separate page and send via email to application@KeystoneFactoring.com or fax to 727-231-8788.

DOLLAR AMOUNTS OF A/R NOW OPEN
Total Outstanding: $ *If you are a start-up business, just put $0 in the table.
1-30 days old: $  
31-60 days old: $  
61-90 days old $  
91+ days old: $  
If available, please email current A/R Aging Report to application@KeystoneFactoring.com or fax to 727-231-8788.


GENERAL INFORMATION
Annual Sales: Avg. Monthly Sales: Monthly amt. to be factored in:
Avg. gross profit %: # of active customers: Avg. invoice size:
Largest Customer: % of business:  
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:  
Do you currently have a loan or line of credit for the business? YES NO
Are any of your receivables pledged as collateral? YES NO
Have you ever filed for personal or corporate bankruptcy? YES NO
Any Federal, State, or Payroll taxes past due? YES NO
Are there any judgments pending by or against the company? YES NO
Is there any pending or threatened litigation against the company? YES NO
Do you process your own payroll? YES NO
Have any of the principals (I.E., directors, officers, shareholders, partners, members) been involved in a business similar to that of applicant within the last 5 years? YES NO
 
FOUR LARGEST ACCOUNTS TO BE FACTORED
Information is for credit research only. Your customers will NOT be contacted by us.
Customer #1 Name:
Street Address: Apt./Suite:
City: State: Zip:
Avg. monthly sales to this customer: $ % of total business:  
Avg. time it takes to get paid (in days): Credit line desired for this customer: $  

 

Customer #2 Name:
Street Address: Apt./Suite:
City: State: Zip:
Avg. monthly sales to this customer: $ % of total business:  
Avg. time it takes to get paid (in days): Credit line desired for this customer: $  

 

Customer #3 Name:
Street Address: Apt./Suite:
City: State: Zip:
Avg. monthly sales to this customer: $ % of total business:  
Avg. time it takes to get paid (in days): Credit line desired for this customer: $  

 

Customer #4 Name:
Street Address: Apt./Suite:
City: State: Zip:
Avg. monthly sales to this customer: $ % of total business:  
Avg. time it takes to get paid (in days): Credit line desired for this customer: $  
 

MESSAGE:


I hereby subscribe and affirm that all the information provided is true and accurate. Keystone Capital Funding, LLC is authorized (as deemed necessary) to verify the accuracy of the statements and information provided and to conduct a credit investigation and background (including criminal) check, including without limitation, obtaining one or more credit reports from credit bureaus. Any adverse material change to the financial condition previously supplied must be reported within fifteen (15) days.