Step 1 of 3 33% APPLICANTYour IndustryDistributionManufucturingProfessional ServicesStaffingTechnologyTransportationComplete Legal Name of Business*Phone*Business Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Trade NameMC Number*WebsiteEmail* # of Years in Business*Federal Tax ID*Type of Business*Sole ProprietorshipPartnershipCorporationLLC# Of Years As Driver*# Of Years Owner-Operator*Operating Insurance Carrier*EXISTING FLEET SIZE# Trucks/Trailers Financed# Trucks/Trailers Leased (Capitalized)*# Trucks/Trailers Owned*# Trucks Total*# Trailers Financed*# Trailers Leased (Capitalized)*# Trailers Owned*# Trailers Total* GUARANTORS / PRINCIPALSName of Principal / Guarantor #1 First MI Last First, MI, LastGuarantor #1 Email Guarantor #1 Date of Birth* Date Format: MM slash DD slash YYYY Guarantor #1 Social Security #*Homeowner?YesNoIf Yes, How Long?Guarantor #1 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Name of Principal / Guarantor #2 First MI Last First, MI, LastGuarantor #2 Email Guarantor #2 Date of Birth Date Format: MM slash DD slash YYYY Guarantor #2 Social Security #Homeowner?YesNoIf Yes, How Long?Guarantor #2 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country ACCOUNTS RECEIVABLE INFORMATIONAccounts Receivable TotalCurrent31-6061+Average Monthly Sales# of Active CustomersAverage Invoice AmountAre You Currently Receiving Quick Pay from Brokers?YesNoIf yes, # of Active Quick Pay CustomersHave your receivables been financed or factored before?YesNoIf yes, explainAre your receivables currently financed or factored?YesNoIf yes, with whomIs the company now, or has it ever been in bankruptcy?YesNoIf yes, explainDo you have any Federal or State taxes past due including, but not limited to, withholding taxes?YesNoIf yes, explainDo you have any Contra Accounts (do you buy and sell to the same customer)?YesNoIf yes, explainDo you have any Guaranteed Sales?YesNoIf yes, explainDo you use a payroll service?YesNoIf yes, whomDo you currently have a fuel card?YesNoIf no, are you interested in obtaining a fuel card?YesNoAre you interested in Back Office Accounting Services?YesNoDo you currently have Extended Warranty Coverage for your equipment?YesNo DOCUMENTS REQUIREDDriver's License Copy for all Owners and Officers Drop files here or Accepted file types: pdf, jpg, jpeg, gif, png. Articles of Incorporation or LLC Operating AgreementAccepted file types: pdf, doc, docx.Current Aging of Accounts ReceivableAccepted file types: pdf, xls, doc.Customer List with Addresses and Phone NumbersAccepted file types: pdf, xls, doc.Copy of the Company's Operating Insurance CertificateAccepted file types: pdf, jpg, jpeg.Copy of your Operating AuthorityAccepted file types: pdf, doc, docx.Copies of Invoices for Funding Drop files here or Accepted file types: pdf, doc, docx, xls. Applicant understands that ENGS Commercial Capital intends to rely on the foregoing information in determining whether to enter into a factoring agreement, and applicant authorizes ENGS Commercial Capital to do so. Applicant also understands that the foregoing information may be incorporated by reference into an agreement between Applicant and ENGS Commercial Capital and any failure of Applicant to disclose truly, completely and correctly the information requested may constitute a breach of any such agreement. Applicant understand further that ENGS Commercial Capital has not, by requesting the completion of or accepting this application form, committed to make or implied intention or commitment to enter into a factoring program with Applicant. Applicant acknowledges that Applicant has retained a copy of this Application. Applicant hereby acknowledges consent to receive text and email messages sent by an automatic telephone dialing system. Consent to these terms is not a condition of funding. Message and data rates may apply. Applicant authorizes ENGS Commercial Capital (and any officer, employee, affiliate or other representative thereof) to obtain a consumer credit report through a credit reporting company chosen by ENGS Commercial Capital. Applicant hereby authorizes ENGS Commercial Capital (and any officer, employee, or other representative thereof) to visit and inspect any properties of Applicant; to discuss Applicant and its affairs, finances, and accounts with, and be advised as to the same by Applicant’s officers, employees, and independent public account; all to such reasonable extent as ENGS Commercial Capital seeks such information in good faith in connection with the within factoring application. Applicant hereby authorizes ENGS Commercial Capital to immediately file a UCC financing statement covering all collateral of Applicant. The financing statement will become effective when (and if) Applicant and ENGS Commercial Capital enter into a factoring agreement. In the event Applicant and ENGS Commercial Capital fail to enter into a factoring agreement, ENGS Commercial Capital will file a termination statement. Applicant hereby authorizes its suppliers, customers, lenders, accountants, principals, officers, and attorneys to provide ENGS Commercial Capital (and any officer, employee, or representative thereof) such information about Applicant and its affairs, finances, and accounts as ENGS Commercial Capital may request. Applicant also authorizes each such person and firm to accept a copy of this Authorization as if it were an original. Guarantor #1 Full Name*Electronic Signature Agreement - Guarantor #1* I Accept By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. You further agree that your use of a key pad, mouse or other device to type your name constitutes your signature as if actually signed by you in writing.Guarantor #2 Full NameBy filling in your full name above and entering a digital signature below you indicate you have read and agree to the above APPLICATION TERMS.Electronic Signature Agreement - Guarantor #2 I Accept By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. You further agree that your use of a key pad, mouse or other device to type your name constitutes your signature as if actually signed by you in writing.