Dear Client,

Please fully complete this application to the best of your ability. Answer all appropriate questions on this application even if it is a negative issue. You will want to let your new Funding Source know as much as possible. Our job is to help you get the cash you need. Any negative issues are not intended to disqualify you, but to allow us to confront these issues head on. So be accurate and truthful to the best of your knowledge. This is very important. You don't want to waste time, slow down your application, or not receive a quote at all!

Upon completion and submission of this form, you will receive an immediate email with your confirmation and funding source information. Please add “globalquickcapital.com” to your allowed email to ensure delivery.

Please note that these Applications are for conducting cash flow business or applying for loans only! These are not job applications!

Thank you,
GlobalQuick CAPITAL

Medical Accounts Receivable Factoring/Funding Application

Requirements

Minimum: Case by Case
No Maximum
Accepted Locations: U.S.A.
Adults 18 and over only

Contact

•Contact First Name:

•Contact Last Name:

Title:

•Email Address:

•Phone Number:

Fax Number:

Cell Number:

Information on Your Business

Who is your billing company?

Contact Name:

Phone Number:

What software are you using for billing/AR?

Is your company capable of transmitting billing information electronically?

Yes No

What is Your Monthly Gross Billing Volume:

Average Net Collectible Percent:

How much of your average monthly billing to you intent to factor each month?

Has your company ever factored receivables?

Yes No

If, Yes, with whom?

Has the Applicant or Principal(s) ever been arrested or convicted of a felony?

Yes No

If yes, please explain:

Are payroll taxes current?

Yes No

If not, delinquent amount:

Are Federal taxes current?

Yes No

If not, delinquent amount:

Are State taxes current?

Yes No

If not, delinquent amount:

If delinquent above, please explain:

How much bad debt did you write off last year?

Has the Applicant or Principal(s) ever granted any security interest in your medical accounts receivable?

Yes No

If yes, please explain:

Do you have any outstanding business or practice loans?

Yes No

If yes, with whom:

Accounts Receivable Information

Total amount of receivables open:

Average Invoice Size:

Average Monthly Sales:

Approximate Number of Active Accounts:

Listing of Principal Accounts/Clients

•Name of Client:

•City:

•State:

Average Monthly Billing:

•Name of Client:

•City:

•State:

Average Monthly Billing:

•Name of Client:

•City:

•State:

Average Monthly Billing:

•Name of Client:

•City:

•State:

Average Monthly Billing:

•Name of Client:

•City:

•State:

Average Monthly Billing:

Comments

Additional Comments:

•How did you hear about GlobalQuick CAPITAL?

Who Referred You?

No one referred me:

Referred Name:

Referred Phone:

Referred Email:

Application Id:

20241221-065414-266

Please note:

The Funding Source may require copy of additional documents
to make your quote. They will let you know by Email.

Upon submission of this form, you will receive an immediate email with your confirmation and funding source information. Please add “globalquickcapital.com” to your allowed email to ensure delivery.

Apply online for a free no obligation quote: Response in 24 to 48 hours in most cases. Our funding sources will be happy to answer all your questions at that time!

We are proud members of the cash flow/growing wealth industry.

We are a
green
company!

We at GlobalQuick CAPITAL believe in giving back to help in this world! A portion of the profits from our earnings will be given to: Heart Research, Arthritis Research, Endangered Animal Species, and Rain Forest Preservation.