FleetFactor Express Application

Company Legal Name

DBA or Trade Name

Physical Address

City State ABALARAZBCCACOCTDCDEFLGAIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNVNYOHOKONORPAPEPQRISCSDSKTNTXUTVTVAWAWIWVWYYT Zip Country United StatesCanada

Telephone    Fax    MC Number

Email Address Re-Enter Email Address

Business Entity CorporationPartnershipLimited Liability CompanySole Proprietor or DBA Date Established Federal Tax ID

Company Equipment

Number of Trucks Number of Trailers

Estimated Sales Volume

Last 30 Days Last 12 Months

Estimated Invoice Information

Average Invoice Amt Average Days Paid Invoices Per Month

Broker and Shipper Accounts

Number of Accounts Accounts to Factor

1.  Has your company ever factored or pledged its accounts receivable?

Yes

No

2.  Are your company's accounts receivable currently factored or pledged?

Yes

No

3.  Is your company's equipment being financed?

Yes

No

4.  Does your company have past due County, State or Federal taxes?

Yes

No

5.  Does your company have any tax liens filed against it?

Yes

No

6.  Has your company ever been insolvent or filed bankruptcy?

Yes

No

7.  Is your company currently engaged in or facing potential litigation?

Yes

No

We appreciate your interest in FleetFactor and want to reaffirm that by submitting this online application, your company is not obligated to enter a factoring agreement. Unlike other factoring companies, we will not file UCC financing statements or perform credit analysis at this stage of the application process. You will automatically receive an email copy of the rate quote.

Your First and Last Name

First Name Last Name

By submitting this application, you acknowledge the information provided is true and correct to the best of your knowledge. You further understand and agree the preliminary online rate quote you are about to receive will be formulated on this initial information and may be subject to improve or change based on potential due diligence.