Funding Request - Liquid Capital of Colorado - Longmont, CO

Please provide us with the information requested below. Information will be confidential (Privacy Policy). USE THE TAB KEY TO MOVE AROUND THE FORM. When you are finished, click the Submit button to send the form. DO NOT PRESS THE ENTER KEY OR THE FORM MAY BE SUBMITTED BEFORE YOU ARE READY.

*General Information - President/Owner/Contact

First Name

Last Name

Company Name

Trade Name

Type of Business

Website

Business Address

City

State/Province

Zip/Postal

Telephone #

Cell #

Fax #

Best Time to Call

Comments

(Optional) Accounts Receivable

Terms of Sales

Average Monthly Sales to be Factored

Total A/R

(Optional) Five Largest Accounts to be Factored

Customer Name	City	Amount