PRE-QUALIFICATION APPLICATION

Please Type In Your Information and Print for Your Records

Download Application PDF

COMPANY INFORMATION
* Legal Name of Company
* Trade Name / DBA
* Billing Address
* MC #
* Fed ID #
* Year Established
* Legal Status	Corp LLC Sole Prop Partnership
* Type of Business	Transportation Broker Transportation Carrier
* Telephone #	(###)###-####
Fax #	(###)###-####
Email
Estimated Monthly Factor Volume
How many trucks do you own?
* Full Name of Owner/Applicant	Last First MI
* % of Ownership
* Social Security #
* Date of Birth
* Home Telephone #
* Home Address
* City * State * Zip
* Marital Status	Married Single

*Spouse's Full Name	Last First MI
*Spouse's Social Security #

Full Name of Co-Owner/Co-Applicant	Last First MI
% of Ownership
Social Security #
Date of Birth
Home Telephone #
Home Address
City State Zip
Marital Status	Married Single

*Spouse's Full Name
*Spouse's Social Security #

Other Owners	Yes No
LEGAL CONSIDERATIONS
* Are any Federal or State Tax Liens filed or threatened? Yes No
* Are the company's Accounts Receivable pledged to any party? Yes No
* Have any companies owned or controlled by the officers ever filed bankruptcy? Yes No
* Has your company ever had different ownership? Yes No
* What will the factoring funds be used for?
* indicates required items
DECLARATION By clicking the “SUBMIT” button below, you understand and agree that Capital Associates Inc. (“Capital”) may provide to you by electronic means any required state and federal law disclosures, notices and communications in connection with your application for Financial Services with Capital, as well as any terms and agreements imposed by Capital in connection with the extension of Financial Services to you. You acknowledge that by agreeing to receive such electronic communications through this website, you demonstrate that you can access information that Capital would provide to you by posting electronic communications on Capital’s website. You may withdraw your consent by not submitting this electronic application. However, you may not apply online unless you consent to receive electronic communications from Capital. In order to access and retain the electronic communications delivered to you by Capital, you must have a working internet browser and email account, a means to print or store notices and information received through your browser and/or email software, and a personal computer or equivalent device capable of connecting to the internet via dial-up, DSL, cable modem, wireless access protocol, or equivalent, and that supports the foregoing requirements. If you do not wish to receive electronic communications from Capital, do not click the “SUBMIT” button below. Instead, click the “Download Application PDF” button below, print out the application, and then complete the application and mail it to Capital Associates at 2594 E Barnett Rd. Ste. C Medford, OR 97504 or fax it to Capital at (541) 773-3407. All communications from Capital to you, whether in electronic or paper format, will be considered to be “in writing”. You should print or download a copy of this Pre-Qualification Application and any other communication that is important to you for your records. You acknowledge that by clicking the “SUBMIT” button below, you are indicating your intent to sign this Pre-Qualification Application and that this shall constitute your electronic signature. You further represent and warrant that the information supplied by you in this Pre-Qualification Application is true and correct to the best of your knowledge and belief, and that you have authority to submit the information to Capital. By clicking the “SUBMIT” button below you authorize Capital to obtain personal and business credit and/or financial information for you and your business from your bank(s), insurance companies, accountants and other financial institutions or commercial firms with whom you and/or your business have done business, as well as credit reporting agencies. It is understood that any such credit and/or financial information will be held in strict confidence and used only for the purpose of evaluating your credit worthiness in connection with an application for business credit. The submission of this Pre-Qualification Application does not obligate Capital to provide you with any financial services whatsoever, and that approval of your application and the extension of any financial services to you by Capital may occur only after the management of Capital approves said application and the financial services offered are approved in accordance with the terms of Capital’s Agreement with you. You acknowledge and agree that your consent to receive electronic communications is being granted in connection with a transaction affecting interstate commerce that is subject to the federal Electronic Signatures in Global and National Commerce Act, and that you and Capital both intend that the Act apply to the fullest extent possible to validate Capital’s ability to conduct business with you by electronic means.
The above statement is true and accurate to the best of my information and belief.
Date
Signature (first and last name)
Title (position in company)

Capital Associates Inc.
Phone: 800-727-3377 • Fax: 541-773-3407