Cb Thomas & Associates Funding

Funding Application

1. Legal Name
2. Phone Number
3. Trade Name
4. Street Address
5. City County State
6. Zip.

7. Federal Taxpayer ID Number
8. President, sole Proprietor, or senior Partner: Name
%Owned
Home Address City
State Zip
Home Phone Number Social Security Number
Date of Birth

9. Secretary or Other Partner: Name % Owned
Home Address City State
Zip Home Phone

10. Name of Accountant Firm
Phone Street Address
City State Zip

11. Name of Attorney Firm
Phone Street Address
City State Zip

12. Name of Bank Bank Officer
Phone Account Number
Street Address City State
Zip

13. Do you have any federal or State Taxes past due? YES
NO
If yes, has lien been filed? YES
NO
If yes, please list type and amounts

14. If leasing space, Name of Landlord Phone
15. What is the purpose of the funds to be generated from factoring?

16. Have you Factored before? YES
NO
Have you ever applied for factoring with any other company? YES
NO
If Yes with what company?
17. Are receivables/inventory/equipment pledged as collateral? YES
NO
18. Any litigation pending against the client or owner/officer? YES
NO
Any judgments outstanding? (Fax copy to 1-888-221-1895) YES
NO
Any Federal or state Tax Liens? (Fax copy to 1-888-221-1895) YES
NO
Has any owner/officer ever been convicted of a felony? YES
NO
Has any owner/officer ever been involved in a bankruptcy? YES
NO

If a yes answer to any of the above questions, please explain fully in the space provided below.

19. Please fax the following to (1-888-221-1895) and check the boxes:
Copies of Articles of inc. and By Laws
Copy of Fictitious Name filing (if applicable)
Copy of Partneership Agreement (if applicable)
Client financial statements
Schedule of aged accounts receivable
Copy of 941 withholding tax filings and proof of payment

I/We fully understand that the submission of an application for the purpose of accounts receivable by

Cb Thomas & Associates Funding (hereinafter "Broker") does not mean that a factor will Factor or provide any service to Application whatsoever. YES

I/we fully understand that approval by a Factor may come only after Factor approves the application and all accounts/invoices offered in accordance with the terms of the Accounts Receivable Purchase Agreement. YES
The statements made herein and all information in all documents provided herewith are true and correct and the Applicant understands that the Factor intends to rely thereon in determining whether to enter into a factoring relationship. YES

Applicant hereby authorizes its suppliers, customers, accountants, attorneys, employees,and credit agencies to provide Factor any information about Applicant and its affairs, finances, and accounts as Factor or its employees may request. By checking this block you are giving Factor authorization. YES

Applicants Name
Email Address
Title
Date