Medical Factoring Application

FIRST NAME:
LAST NAME:
TITLE:
COMPANY:
STREET:
CITY:
STATE:
ZIP CODE:
PHONE:
FAX:
EMAIL:

Total Receivables Outstanding:
1-90 Days Outstanding
Approximate Monthly Billings:
Approximate Monthly Collections:

Average Number of Days to Collect:

Please briefly describe your business:

FactoringMEDICAL may get in touch with me:
MON. TUE. WED. THURS. FRI. SAT.
9:00AM-11:00AM 1:00PM-5:00PM
When would you like to have your account read to fund?
Comments: