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Company Name:
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Contact (Full) Name:
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Address 1:
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Address 2:
City
:
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State:
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Alaska
Alabama
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Arizona
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Zip Code:
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Phone Number 1:
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Phone Number 2:
Fax Number:
Best time to contact you:
E-mail Address:
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Operating Since:
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[mm/yyyy]
Type of Business:
Select One..
Accounting (CPA)
Aerospace
Agricultural
Aircraft
Apparel
Architect
Attorney
Automotive Parts
Automotive Service
Beverage
Bio-Tech
Chiropractor
Computer Hardware
Computer Software
Construction
Consulting
Consumer Products
Couriers/Messengers
Defense
Dental Technology
Dentist
Distribution
Education Related
Electronics
Energy
Entertainment
Environmental
Existing Technology
Federal Government
Film, Play, Video
Financial Services
Fitness
Food Service
Forestry and Fishing
Funeral Home
Gaming
Garment
Gasoline Station
Health Products
Healthcare
Hi-Technology
Import/Export
Industrial Products
Insurance
Internet/Online Services
Legal Profession
Lodging
Manufacturing
Marine
Media Production
Medical ("ologists")
Medical (licensed)
Medical (therapists)
Medical Technology
Mobile Home Parks
Mortician
Municipal
Natural resources
New Technology
Optometry
Pharmacist
Pharmaceuticals
Piece Goods
Printing
Psychologists
Publishing
Real Estate Related
Resorts
Restaurant
Retail
Security
Semi-Conductors
Service Related
Space Technology
Staffing
Telecommunications
Textiles
Titled Vehicles
Transportation
Trucking
Veterinary Technology
Veterinarian
Warehousing/Storage
Waste or Recycling
Wholesale
*
Monthly Gross Sales:
Select One..
0 - $2,000
$2,001 - $10,000
$10,001 - $20,000
$20,001 - $30,000
$30,001 - $40,000
$40,001 - $50,000
$50,001 - $60,000
$60,001 - $70,000
$70,001 - $80,000
$80,001 - $90,000
$90,001 - $100,000
$100,000 - $200,000
$200,000+
*
Monthly Credit-Card Sales:
Select One..
0 - $2,000
$2,001 - $10,000
$10,001 - $20,000
$20,001 - $30,000
$30,001 - $40,000
$40,001 - $50,000
$50,001 - $60,000
$60,001 - $70,000
$70,001 - $80,000
$80,001 - $90,000
$90,001 - $100,000
$100,000 - $200,000
$200,000+
How did you hear about us?
Select One..
BusinessFinance.com
Current Customer
Mag/Newspaper ad
Mailer
Other
Sales Rep
Score.org
Search Engine
Trade Show/Conference
Word of Mouth
Radio
TV
Newspaper
Magazine
Fax
Email
Trade Exchange
Other
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Please specify:
If you have already spoken with one of our Sales Representatives, please enter their name:
Additional Comments:
Privacy Assurance:
Xpress Business Funding, Inc. respects our clients' privacy desires. The private information you are submitting will be kept confidential and will not be resold to third parties.
Sales & Marketing:
16 Standish Drive Scarsdale NY 10583
PH: 800-787-8852 FX:914-725-6851
TRADE EXCHANGES CLICK HERE
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