Client Qualifier Application

Genesis Establishes Partnerships to Bring Alternative Funding Options to Help Achieve Your Business Goals

Please note that all information provided will remain confidential and will not be disclosed to any third party.

Company Name
Company Address
Contact Person
Contact Email Address
Contact Phone Number
Industry
Revenue Last 12 Months
or Monthly Sales

Check One:

Amount of Business Loan to Borrow
Amount of Commercial Loan to Borrow
Volume Expected to be Factored (Monthly)
Average Invoice Amount
Credit Terms

Customers to be Factored (Provide at Least One)

Name
% of Sales
Address
Name
% of Sales
Address
Name
% of Sales
Address
Current Accounts Receivable Balance
Secured Creditors (UCC Filings, Tax Liens, ETC.), if Any
Taxes Due or Past Due (If Any)

Type of Financing Needed for Business or Commercial Loans (Check One):

Working Capital
Equipment Finance
Refinance Existing Debts
Other