Referring Partner Company Name
Referring Partner Full Name
Referring Partner Phone #
Referring Partner Email
Provider Company Name
Provider Fictitious Name or DBA
Tax ID #
Contact Person / Administrator
What type of facility is it? (Physician, MRI, Hospital, DME, etc…)
How long has the company been operating?
Please provide brief history and overview of the company
Why is the company seeking financing and/or interested in selling its receivables?
How much money are you seeking?
Has the company previously received financing or attempted to sell its receivables? If so, please provide reason and outcome.
Are there any current liens against the accounts receivable? If so, please state whether it's a bank, IRS or other lien and for how much.
NONE BANK IRS OTHER
Does the company use a 3rd party billing/collection company? If so, how long has the contract been in place?
What is the monthly gross billed amount average over the last two years? If not applicable, write N/A
What is the company's monthly operating expense?
Where does the company bank? (Chase, Wells Fargo, etc…)
How many W2 employees does the company have?
How many 1099 contractors does the company have?
How many locations does the company operate from?
How does the company generate its business, i.e. referral sources?
Has the company or any of its principals ever been involved in bankruptcy proceedings? If yes, please explain.
Are there any claims, actions, suits or judgments current or pending against the company or its principals? If yes, please explain.
Have any of the principles, owners, managers, or operators of the company ever been charged or convicted of any crimes? If yes, please explain.
Does the company do its own payroll? If not, is there a 3rd party?
Are Payroll taxes current? If not, what's the delinquent amount?
Are Federal taxes current? If not, what's the delinquent amount?
Are State taxes current? If not, what's the delinquent amount?
Please provide any additional information you deem necessary for evaluation of your request for financing / sale of receivables.
By signing below or submitting your name electronically, the Borrower, its owners/principals, or representatives filling out this application: (1) certify that all information and documents submitted in connection with this Application is true, correct and complete; and (2) authorize Alleon Capital Partners, LLC and its affiliates to receive credit reports and any other background information regarding the Borrower and its owners/principals from third parties, to verify any information provided on this application.
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