Diversified Residential and Commercial Services, Inc.
421 Seventh Avenue
New York, NY 10001

212-714-1027

 Accounts Receivable Financing Application Form


  Contact Information
    Actual Business Name:     ( Required )
    Year Established:    
    Trade Name:     ( if different from above )
    Street Address:    
    Address (Cont):    
    City:    
    State / Province:    
    Zip Code:    
    Country:    
    Work Phone:     ( Required )
    Home Phone:     ( Required )
    FAX:    
    E-mail:     ( Required )
    Previous business names used in the last five (5) years:    

  Business Information
    Type of Entity:    
      Corporation     Partnership  
      Sole Proprietorship     Limited Liability Company  
      Other     ( if other please specify )  
    If a corporation, in which state are you incorporated?    
    Year of Incorporation:    
    Federal Tax Number:    
    State Tax Number:    

  Owner's (Stockholders) / Officers Information
    Owner      
    Name and Title:    
    Address:    
           Own  Rent
    Telephone:    
    D / L #:    
    State D / L #:    
    Social Security Number:    
    Date of Birth:    
     
    Owner      
    Name and Title:    
    Address:    
           Own  Rent
    Telephone:    
    D / L #:    
    State D / L #:    
    Social Security Number:    
    Date of Birth:    

  Current Receivables
    Factored Before?      Yes   No 
    Approx. number of accounts:    
    Terms of sale:    
    Average monthly sale:    
    Average # of invoices monthly:    
    Average invoice amount:    
    High credit for indiv. account:    
    Average days A / R turnover:    

  Insurance
    Fire Insurance      Yes   No 
    Inventory Dollar Amount:    
    Equipment & Fixtures:      Yes   No 
    Building:      Yes   No 

  Customer Information
    Customer Name:    
    Customer Telephone:    
           
    Customer Name:    
    Customer Telephone:    
           
    Customer Name:    
    Customer Telephone:    

  Tax Information
    Are your taxes past due?      Yes   No  ( if yes please complete the following )
    Federal:    
    Agent Name:    
    Telephone:    
           
    State:    
    Agent Name:    
    Telephone:    
           
    Local:    
    Agent Name:    
    Telephone:    
           
    Employment:    
    Agent Name:    
    Telephone:    
           

  Please List Principal Suppliers
    Name:    
    Address:    
    City:    
    State:    
    Zip:    
    Telephone:    
           
    Name:    
    Address:    
    City:    
    State:    
    Zip:    
    Telephone:    
           
    Name:    
    Address:    
    City:    
    State:    
    Zip:    
    Telephone:    
           
    Name:    
    Address:    
    City:    
    State:    
    Zip:    
    Telephone:    
           

  Loans & Financing
    Are any assets now assigned, pledged, or liened as collateral for a loan or other financing?
           
    Accounts Receivable:      Yes   No  ( if yes please complete the following )
    Name:    
    Address:    
    City:    
    State:    
    Zip:    
    Telephone:    
    Inventory:      Yes   No 
    Equipment:      Yes   No 
    Fixtures:      Yes   No 
    Other:      Yes   No 

  Form Submission
    Who refered you to our service?    
           
    By submitting this form, you authorize, Diversified Residential and Commercial Services Inc., and or its agent(s) to verify all information provided and to perform a background and credit check on all principal shareholders, partners, and/or officers of the company.
    I prefer being contacted by:  
      E-mail       Business Phone       Home Phone