J&D Financial Purchase Order Broker Referral Form

Broker Quick Referral Form
Company Being Referred:
Business Name:
Contact Name:
Title:
Street Address:
City:
State / Zip:
Country:
Phone:
Ext:
If outside USA, country code:
City code:
Fax:
Email:
Web site:
How did you find us?
If "Other" please describe:
Description: Please provide a brief description of your company.
Are Your Customers:	Domestic Import Export
Where Are They Located:	North America South America Asia Europe Africa

What is your average monthly sales volume? $
How much of your average monthly billing do you wish to factor? (%)
Have you ever factored your receivables?	Yes No

If yes, with whom:

Total Accounts Receivable: $
Receivables > 90 days from invoice date: $
Does the Company or its Owners have any judgements or liens filed against them?	Yes No
Does the Company or its Owners have any pending law suits against them?	Yes No
Do you have any outstanding loans?	Yes No

If yes, with whom: Name of Financial Institution
Balance Owed: $

Do you have any UCC Filings:

Yes No

If yes, with whom:

Or are your receivables pledged as collateral:

Yes No

Please List Company's 5 Largest Customers You Wish To Factor (Note: Customers will NOT be contacted initially)
Company Name:
Address:
City:
State / Zip:
Monthly Sales: $
Average Invoice Amount: $
Company Name:
Address:
City:
State / Zip:
Monthly Sales: $
Average Invoice Amount: $
Company Name:
Address:
City:
State / Zip:
Monthly Sales: $
Average Invoice Amount: $
Company Name:
Address:
City:
State / Zip:
Monthly Sales: $
Average Invoice Amount: $
Company Name:
Address:
City:
State / Zip:
Monthly Sales: $
Average Invoice Amount: $
Message:
I am interested in:	Domestic Factoring Purchase Order Financing International Factoring Government Factoring Construction Factoring Business Loans Trade Financing