Application United Capital Funding Quick Application Save my progress and resume later | Resume a previously saved form Resume Later In order to be able to resume this form later, please enter your email and choose a password. Your Email: A Password: Confirm Password: Business Information No cost to apply. Information submitted in this application is secure and confidential. For questions regarding this application, please call (877) 894-8232.This site is secure, all information submitted on this page is private. Business Information Name of Company DBA Address City StatePlease select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Telephone Fax Email Address Website Federal Tax I.D. Number State Registered InPlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau County Registered In Legal StructureCorporationPartnershipLLCSole ProprietorOther Type of Business/Industry Business Start Date Ownership Information Ownership Information First Name Last Name % Ownership Title Home Address City StatePlease select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Telephone Cell Email Address Social Security Number Social security numbers are required to process the application. We can gather this over the phone later if you prefer not to submit it now. Are there other owners/partners?YesNo Ownership Information First Name Last Name % Ownership Title Home Address City StatePlease select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Telephone Cell Email Address Social Security Number Social security numbers are required to process the application. We can gather this over the phone later if you prefer not to submit it now. Accounts Receivable Dollar Amount of Commercial Accounts Receivable now open: Total Outstanding Current 30 Days Old 60 Days Old 90 Days Old Do you currently have a loan or line of credit for the business?YesNo If yes, to whom Are you currently factoring?YesNo If yes, to whom Do you have a contract?YesNo Expiration Date of the Contract Do you process your own payroll?YesNo Have you ever filed for personal/corporate bankruptcy?YesNo Any Federal or State taxes past due?YesNo Are there any judgments pending by or against the company?YesNo Any pending or threatened litigation against the company or any principal?YesNo Accounts to be Factored Accounts to be Factored: Please supply the complete name, address, and credit limit. Use the "Add Another Account to Be Factored" link below the first account to add the next. Account Customer Name Street Address (No PO Box) City StatePlease select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Average Monthly Sales for This Customer Average Time it takes to get paid Current Credit Limit for This Customer Current Outstanding Accounts Receivables Where did you hear about us? By submitting this application, you authorize United Capital Funding to use any credit bureau or business to verify any information that is provided. United Capital Funding Group, LLC is a wholly owned subsidiary (WOS) of Gulf Coast Bank & Trust Company, New Orleans, Louisiana. Gulf Coast Bank & Trust Company is an FDIC-insured commercial bank. reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Save my progress and resume later | Resume a previously saved form
