Funding you
forward.

To establish an account with us, fill out the online application below or complete our downloadable application. Once you’ve submitted the information we will review it and contact you for further instruction.

short term funds. long term impact.

Mazon Associates, Inc. Application

To establish an account with us, fill out the online application below or complete our downloadable application. Once you’ve submitted the information we will review it and contact you for further instruction.

When you complete a page and click on the Next button, all the information you entered on that page is saved. You can leave our website and resume it later.

Note: You must use the same computer to resume the application.

Mazon Application Long Form

Company Information

Legal name of company

Business address

Street address

City

State

Zip code

Do you have a different mailing address?

No

Yes

Mailing address

Street address

City

State

Zip code

Do you have a company website?

Yes

No

Website

Business description

Year established

Federal Tax ID

Type of business

State Incorporated

LLC Tax Classification

1. Principle / Member / Owner

First name

Last name

Suffix

Title

Ownership %

%

Phone

Social Security #

Date of Birth

Drivers License #

Drivers License State

Residence address

Street address

City

State

Zip code

Do you own or rent your residence?

Own

Rent

Add a Second Principle, Member or Owner?

No

Yes

2. Principle / Member / Owner

First Name

Last Name

Suffix

Title

Ownership %

%

Phone

Social Security #

Date of Birth

Drivers License #

Drivers License State

Residence address

Street address

City

State

Zip code

Do you own or rent your residence?

Own

Rent

Add a Third Principle, Member or Owner?

No

Yes

3. Principle / Member / Owner

First Name

Last Name

Suffix

Title

Ownership %

%

Phone

Social Security #

Date of Birth

Drivers License #

Drivers License State

Residence address

Street address

City

State

Zip code

Do you own or rent your residence?

Own

Rent

Add a Fourth Principle, Member or Owner?

No

Yes

4. Principle / Member / Owner

First Name

Last Name

Suffix

Title

Ownership %

%

Phone

Social Security #

Date of Birth

Drivers License #

Drivers License State

Residence address

Street address

City

State

Zip code

Do you own or rent your residence?

Own

Rent

Financial Information

Avg. Monthly Revenue ($)

Current A/R balance ($)

Avg. invoice amount ($)

Total factoring amount needed ($)

Please list the customers you want to factor below
(Don't worry, we won't contact your customers without your permission.)

Customer name	Current account balance ($)	Avg. collection days	Factoring amount needed ($)

Other Information

Does your company have any current debt?

Please check all that apply.

Bank loans

SBA loans

Merchant cash advances

Other debt or loans

Please list all your debts below:

Name of debtor	Outstanding debt amount ($)	Does this debtor have a lien on your assets?

Does your company or officers have any of the following?

Please check all that apply.

Federal or state tax liens

Prior bankruptcies

Pending litigation or lawsuits

Please list all tax liens below:

Tax lienholder	Amount you owe ($)

Year of last bankruptcy

Please explain any pending litigation or lawsuit.

Are you currently factoring?

No

Yes

Name of the factoring company

Electronic Signature

Your first name

Your last name

Title

Your work phone

Your cell phone

Your email

Date

Authorization
The confidential information contained in this application is true and correct, and I hereby authorize any credit investigation necessary by Mazon Associates, Inc.