Application

To establish an account with us, you need to 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.

Mazon Associates Application

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
Website
Business description*
Year established*
Federal tax ID*
Business type*
If an LLC or Corporation, in what state incorporated?*
LLC Tax Classification*
Are you a motor carrier?*
- No
- Yes
MC Number*
USDOT Number
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Principles and Owners

1. Principle / Member / Owner
First Name*
Last Name*
Suffix
Title*
Ownership Percentage (%)*
Phone*
Social Security #*
Date of Birth*
Drivers License #*
Drivers License State*
Residence*
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 Percentage (%)*
Phone*
Social Security #*
Date of Birth*
Drivers License #*
Drivers License State*
Residence*
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 Percentage (%)*
Phone*
Social Security #*
Date of Birth*
Drivers License #*
Drivers License State*
Residence*
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 Percentage (%)*
Phone*
Social Security #*
Date of Birth*
Drivers License #*
Drivers License State*
Residence*
Street Address City State ZIP Code
Do you own or rent your residence?*
- Own
- Rent
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Accounts Receivables

Total monthly billings ($)*
Current A/R balance ($)*
Avg. invoice amount ($)*
Monthly factoring requirement ($)*
PRIMARY CUSTOMERS:
For information purposes only; we won't contact your customers at this time.
1. Customer name*
Account balance*
Credit terms (e.g. net 30)*
2. Customer name
Account balance
Credit terms (e.g. net 30)
3. Customer name
Account balance
Credit terms (e.g. net 30)
Do you perform progress billings?*
(This is common in the construction industry.)
- No
- Yes
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Other Information

Does your company have any outstanding loans or advances?*
Please check all that apply.
- Bank loans
- Cash advances
- Other debt or loans
- None of the above
Name of debtor or financial institution*
Outstanding debt or loan amount ($)*
Does this debtor have a secured interest in your receivables or other assets?*
- No
- Yes
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
- None of the above
Tax lien amount*
Please explain the litigation or lawsuit.*
Have you ever worked with a factoring company?*
- No
- Yes
Name of the factoring company*
Email the following items to lisa@mazon.com:
1. DBA Certificate, Inc. Certificate or LLC Certificate, Articles and Bylaws.
2. Accounts receivable aging (unpaid invoices)
3. Customer list (include customer name, address and phone)
4. Financial statements (income statement and balance sheet), if available.
5. Copy of sample invoice with supporting documentation (e.g. purchase order, shipping document, etc.)
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Electronic Signature

Authorization*
- The confidential information contained in this application is true and correct and I hereby authorize any credit investigation necessary by Mazon Associates, Inc.
Name*
Title*
Date*
MM slash DD slash YYYY
Phone*
Email*
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Phone
This field is for validation purposes and should be left unchanged.