Company:

Contact:

Title:

Address:

City, State, Zip

Office Phone:

Cell Phone:

Fax Number:

Email:

Referred By:

Industry/Business Description:

Ownership Status:

FEIN or SS#

Banking Information

Name of Bank:

Checking Account #:

Contact:

Trade References

1-3 Trade References:

Equipment Information

Equipment Description:

Vendor:

Cost:

Financing Term:

The foregoing information is true and correct to the best of my knowledge and is given to induce LKD Funding, LLC to consider entering into a factoring agreement with this company. I hereby authorize LKD Funding, LLC or its agents to verify and investigate any or all of the foregoing statements, including but not limited to my/our credit worthiness and financial responsibility, in any way they may choose. I/We grant LKD Funding, LLC the right to procure any and all credit reports pertaining to any party listed in this application, including, but not limited to, all principals of the applicant company.

Your Name:

Title:

Date: