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About Us
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Why Choose Us
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Case Studies
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Please Fill Out The Form Below
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Please enable JavaScript in your browser to complete this form.
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Step
1
of 5
Legal Name of Business
*
DBA Name
*
Organization Type
*
--- Select Choice ---
Sole Prop
LLC
Corporation
Partnership
Business Street Address
City
*
State
*
Zip Code
*
Phone
*
Email
*
State Registered In
*
Federal Tax ID
*
Next
Number of Owners
*
Name of Owner #1
*
Percent Ownership (Owner #1)
*
Home Street Address (Owner #1)
*
City (Owner #1)
*
State (Owner #1)
*
Zip Code (Owner #1)
*
Phone (Owner #1)
Date of Birth (Owner #1)
Social Security Number (Owner #1)
Name of Owner #2
Percent Ownership (Owner #2)
Home Street Address (Owner #2)
City (Owner #2)
State (Owner #2)
Zip Code (Owner #2)
Phone (Owner #2)
Date of Birth (Owner #2)
Social Security Number (Owner #2)
Name of Owner #3
Percent Ownership (Owner #3)
Home Street Address (Owner #3)
City (Owner #3)
State (Owner #3)
Zip Code (Owner #3)
Phone (Owner #3)
Date of Birth (Owner #3)
Social Security Number (Owner #3)
Name of Owner #4
Percent Ownership (Owner #4)
Home Street Address (Owner #4)
City (Owner #4)
State (Owner #4)
Zip Code (Owner #4)
Phone (Owner #4)
Date of Birth (Owner #4)
Social Security Number (Owner #4)
Name of Owner #5
Percent Ownership (Owner #5)
Home Street Address (Owner #5)
City (Owner #5)
State (Owner #5)
Zip Code (Owner #5)
Phone (Owner #5)
Date of Birth (Owner #5)
Social Security Number (Owner #5)
Name of Owner #6
Percent Ownership (Owner #6)
Home Street Address (Owner #6)
City (Owner #6)
State (Owner #6)
Zip Code (Owner #6)
Phone (Owner #6)
Date of Birth (Owner #6)
Social Security Number (Owner #6)
Next
Are you currently factoring or have you factored before?
*
--- Select Choice ---
Yes
No
Unsure
Who did you work with?
Have you or other owners filed for personal or corporate bankruptcy?
*
--- Select Choice ---
Yes
No
Unsure
When was the bankruptcy filed?
Any federal, state or local taxes past due?
--- Select Choice ----
No
Yes
Unsure
How much is due in taxes?
Any judgments or IRS liens against the company or its owners?
--- Select Choice ---
No
Yes
Unsure
How much is due?
Any pending or threatened litigation against the company or its owners?
--- Select Choice ---
No
Yes
Unsure
Next
Total commercial receivables open in $
0- 30 Days Old $
31- 60 Days Old $
61- 90 Days Old $
More Than 90 Days Old $
How many customer accounts would you like to sell? (1-4)
Pay Average #4)
Business Name (Customer #1)
*
Website (Customer #1)
Average Monthly Sales (Customer #1)
Average Speed of Pay in Days (Customer #1)
Credit Line Requested (Customer #1)
Business Name (Customer #2)
Website (Customer #2)
Average Monthly Sales (Customer #2)
Average Speed of Pay in Days (Customer #2)
Credit Line Requested (Customer #2)
Business Name (Customer #3)
Website (Customer #3)
Average Monthly Sales (Customer #3)
Average Speed of Pay in Days (Customer #3)
Credit Line Requested (Customer #3)
Business Name (Customer #4)
Website (Customer #4)
Average Monthly Sales (Customer #4)
Average Speed of Pay in Days (Customer #4)
Credit Line Requested (Customer #4)
Next
Signature of Completion
*
Please type your name above to affirm completion of the application which serves as permission to KW Receivables for the purpose of accuracy and credit investigation. The statements are true and accurate to the best of my knowledge.
Submit
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