DATE:  ___________________          COMPANY NAME: ___________________________________

ADDRESS: ______________________________________________

PHONE NUMBER: ______________               FAX NUMBER: _____________

CONTACT PERSON: ____________________________ POSITION:_________________________

NATURE OF BUSINESS: _______________________________________________

HOW LONG IN BUSINESS : __________________  MONTHLY VOLUME: _____________________

AVERAGE INVOICE SIZE: _____________________  TERMS: __________________

U.C.C. FILING (LIENS): _______________________   LOAN COLLATERAL:______________________

BANK LOANS: _____________________________

TYPE OF CUSTOMERS: ___________________________

CUSTOMER INVOICES TO BE FACTORED: __________________________________________