Factoring Application - Chris Ball Company InformationExact Legal Name of Company(Required) Trade Name/DBA MC#(Required) Entity Type(Required) Sole Prop LLC Partnership Corporation EIN(Required) Physical Address(Required) City(Required) State(Required) Zip(Required) Mailing Address (if different) City State Zip Phone(Required)Cell PhoneEmail(Required) Freight DetailsTypes of Business (if both apply, check both)(Required) Trucking Broker Products Hauled(Required) Current Monthly Volume $(Required) Anticipated Monthly Volume $(Required) # Trucks Under Your Authority(Required) # Trucks Fully Owned(Required) Do You Have a List of Customers You Work With?(Required) Yes No Number of Agents Work For You(Required) Do You Double Broker?(Required) Yes No Monthly Volume $(Required) Anticipated Monthly Volume $(Required) Person With Significant Responsibility For Above Company Individual who has significant responsibility for managing the legal entity listed above (e.g., President, Vice President, Managing Member, Chief Executive Officer, etc) Full Name(Required) Title(Required) Date of Birth(Required) MM slash DD slash YYYY SSN(Required) Phone(Required)US Citizen(Required) Yes No % of Ownership (input "0" if not an owner)(Required)Home Address(Required) City(Required) State(Required) Zip(Required) Owner, Officer, & Partner (not listed above)Full Name(Required) Title(Required) % of Ownership(Required)Date of Birth(Required) MM slash DD slash YYYY SSN(Required) Street Address(Required) City(Required) State(Required) Zip(Required) Phone(Required)US Citizen(Required) Yes No Additional Owners? Yes Additional Owner, Officer, & Partner (Not Listed Above)Full Name(Required) Title(Required) % of Ownership(Required)Date of Birth(Required) MM slash DD slash YYYY SSN(Required) Street Address(Required) City(Required) State(Required) Zip(Required) Phone(Required)US Citizen(Required) Yes No Additional Owners ? Yes Additional Owner, Officer, & Partner (Not Listed Above)Full Name(Required) Title(Required) % of Ownership(Required)Date of Birth(Required) MM slash DD slash YYYY SSN(Required) Street Address(Required) City(Required) State(Required) Zip(Required) Phone(Required)US Citizen(Required) Yes No Legal ConsiderationsDoes the applicant or owners have any past due taxes or tax liens?(Required) Yes No Does the applicant or owners have any bankruptcies, claims, or lawsuits pending?(Required) Yes No Does the applicant or owners have any other factoring/credit applications pending?(Required) Yes No Promo Code (optional) DECLARATION I, the undersigned opening this account, hereby certify to the best of my knowledge that the information provided above is complete and correct. This certification also includes all forms and documents submitted to Steelhead Finance ("Steelhead") in connection herewith. I/We have been told and do understand that the submission of an application for Financial Services with Steelhead does not mean that Steelhead will provide any financial services whatsoever. I/We further have been told and do understand that approval may come only after the management of Steelhead approves said application and the financial services offered are approved in accordance with the terms of Steelhead's Agreement with Client. I/We understand that I/we may be responsible for any hard costs associated with processing this application. In support of this Application, Steelhead is hereby authorized to obtain personal and business credit and/or financial information from my/our bank(s), insurance company, accountant, and other financial institutions or commercial firms with whom I/we have done business as well as credit reporting agencies. It is understood that any such credit and/or financial information will be held in strict confidence and used only in consideration of this Application. As inducement for Steelhead to process this application, Applicant grants to Steelhead a security interest in their accounts receivables. I/We understand that in the event the Program Offer is terminated by Client after written or verbal acknowledgement, Client shall pay Steelhead the sum of five hundred dollars ($500), which the Parties agree fairly represents the costs and expenses Steelhead will incur in releasing the UCC-1 filed pursuant to the Program Offer, and the Parties further agree that said sum does not constitute a penalty.Full Name Signature of Person Opening Account(Required) Title(Required) I Agree to the Terms & Declaration(Required) Yes Full Name Signature (additional owner if applicable) Title I Agree to the Terms & Declaration Yes Full Name Signature (additional owner if applicable) Title I Agree to the Terms & Declaration Yes Full Name Signature (additional owner if applicable) Title I Agree to the Terms & Declaration Yes CAPTCHA
