England Logistics - Carriers - Factoring

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Legal Business Name

Phone

Assumed Name(s) or DBA(s)

Fax

Address

Date Established

City

State

Zip Code

E-Mail

Type of Business
Corporation LLC Partnership Sole Proprietor

# of Company Trucks

Owner Operator Trucks

MC #

Factored Previously?
Yes No

If Yes, With Whom

Contract Expiration

Please list all Owners and Upper Management

OFFICER #1:
Officer Name

Title

Social Security #

Address

% Owned

City

State

Zip Code

OFFICER #2:
Officer Name

Title

Social Security #

Address

% Owned

City

State

Zip Code

Are there any unsatisfied judgments, tax liens, or lawsuits against you?
Yes No

Have all taxes which are due been paid in full?
Yes No

Have you ever filed bankruptcy or been convicted of a crime?
Yes No

If you answer yes to any of the above questions please describe.

Please check each of the programs of potential interest to your company.
A/R Factoring (for a free rate quote, complete the section below)
Fuel Discounts
Tire Discounts
Truck/Trailer Sales

Referral Source - How did you hear about these programs? (check all that apply)
England employee/agent - name:
Website
Mailing
Other trucking company
Advertisement - location:
Other:

Fleet Name

Officer 1

Title

Fleet Name

Officer 2

Title

ONLY COMPLETE THIS SECTION TO RECEIVE A FREE FACTORING RATE QUOTE

A/R Outstanding Currently

Average Invoice Amount

Approximate # of Customers

Average Monthly Sales

Customer/Broker List (include all companies you intend to factor)

Name #1

MC Number

Phone Number

Current Balance

Name #2

MC Number

Phone Number

Current Balance

Name #3

MC Number

Phone Number

Current Balance

Name #4

MC Number

Phone Number

Current Balance

Name #5

MC Number

Phone Number

Current Balance

Name #6

MC Number

Phone Number

Current Balance

Name #7

MC Number

Phone Number

Current Balance

Name #8

MC Number

Phone Number

Current Balance

Name #9

MC Number

Phone Number

Current Balance

Name #10

MC Number

Phone Number

Current Balance

Applicant and the undersigned individuals certify, represent and warrant that the foregoing information is accurate and complete and does not omit any information necessary to make this Application not misleading. England Carrier Services is authorized to order credit and business reports on Applicant and the undersigned individuals, contact references (whether or not listed on this application) and conduct such other investigation and review as England Carrier Services deems appropriate.

England Carrier Services is authorized to file a UCC Financing Statement against all assets of Applicant upon execution of this Application. If financing is not provided pursuant to this Application, the UCC Financing Statement will be terminated.

Fleet Name

Officer 1

Title