Application - Autumn Capital Group

Business Name *

Date Business Started *

Street Address *

City, State, Zip code *

Phone *

Federal ID Number *

Type of Business *

Form of Organization *

LLC
Sole proprietor
Corporation
Partnership

State of Formation *

Website *

Principal Name *

Social Security Number *

Percentage (%) Owned *

Home Address (City, State, Zip Code) *

Email *

Amount of receivables now open? *

Average Monthly Sales *

Term of Sales *

Are you factoring now or have you factored before? *

I understand that the submission of this document to Autumn Capital Group (ACG) indicates my intention to enter into a Security Agreement with ACG but does not obligate ACG to factor/finance or provide any financial services whatsoever. I further acknowledge that the approval to factor/finance or provide any financial services may come only after the manager of ACG approves said application and the invoices/accounts offered, in accordance with the terms of ACG’s Security Agreement. The above statements are true and correct to the best of my information and belief. This serves as my permission for the release of any information by any party to ACG regarding this application for the purpose of credit investigation. I hereby authorize ACG to investigate the credit of all individuals and entities listed above. I also herein authorize ACG to contact our customers to verify the invoices submitted for factoring.