Amerifund Capital Group, LLC

Submit this form and we will email you a letter of intent within 24 hours, officiating our offer of terms and rates.

Section 1

1. Legal Name of Company (required):
(as shown on the ARTICLES of INCORPORATION or OTHER ENTITY AGREEMENT)

Address:
City:
State:
Zip:
Contact/Position:
Phone:	() -
Fax:
Email Address: (Required)

2. Your business is a:

3. How long have you been in Business?

4. Describe your business:

Section 2
Accounts Receivable Information

5. What is your average monthly billing?

6. How much of your average monthly billing do you wish to factor?

7. What is the average size of your invoice?

Smallest? Largest?

8. Are any of your receivables progress billing?

Section 3
General

9. Company's Attorney:

Phone:

Address:

10. Company's Accountant:

Phone:

Address:

11. Have you previously factored?

12. Name of previous factor?

Thank you for your application. An Amerifund Capital Group financial specialist will contact you within 24 hours.

Home Office: 2881 E Oakland Park Blvd. Suite 411 . Ft Lauderdale, FL 33306

West Coast Office: 2050 W Warm Springs Blvd. Suite 3122 Henderson, NV 89014
Phone: 888.615.8458 / (954) 941-2254 . Fax: 954.537.3085