Client Application

Business Information

Business Name *

Federal Tax ID *

Date Established *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Website / URL

Must include "http://"

Phone *

Fax

Type of Business

Type of Entity *

State of Organization *

Type of Business | Primary Product/Service *

Number of Employees *

Number of Owners/Operators *

Number of Company Trucks *

Federal or State Taxes Past Due? *

Yes
No

Bank Information

Bank/Financial Institution *

Account # *

Branch Location *

Contact Name *

Contact Email *

Contact Phone *

Contact Fax

Professional Services

Attorney Name

Attorney Company/Firm

Attorney Phone

Accountant Name

Accountant Company/Firm

Accountant Phone

Owner Information

How many owners in this company? *

Owner #1 Full Legal Name *

Owner #1 Position/Title *

Owner #1 Social Security Number *

Owner #1 Date of Birth *

Owner #1 % of Ownership *

Owner #1 Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Owner #1 Email *

Owner #1 Phone (Cell/Primary) *

Owner #1 Phone (Home/Other)

Accounts Receivable

Average Monthly Sales *

Accounts Receivable Balance *

Average Invoice Amount *

Average Number of Invoices per Month *

How frequently are invoices generated? *

Are invoices generated prior to receiving signed ticket? *

Yes
No

Are any extended terms granted with the receivables? *

Yes
No

Authorization & Signature

I/we hereby solemnly declare and certify the information supplied in this Application is true and correct to the best of my/our knowledge and that the signer(s) hereto has/have full authority to provide the information. I/we hereby authorize TXP Capital, LLC (TXP) to procure and verify my/our credit worthiness and any other information provided or obtained by TXP in the course of its investigation, which in TXP’s sole discretion it deems appropriate, and to conduct independent background investigation(s) of this applicant(s) and the applicant’s business. I/we further provide authorization, on a continuing basis, for any person or business to release any and all credit reports or verifications to TXP.

Signature

By signing, you agree to the terms above.

Date of Signature *

Who may we thank for referring you?