Online Consultation form

The following documents are required prior to Quotient Industrial Capital LLC and/or it's Assigns consideration of your request for funding:

1.This Application
2.Business financial statement including balance sheet and profit & loss statements
3.A current list of accounts receivable including invoice date, customer name, customer address and invoice amount

Origination Agreement
In connection with this application I authorize FundingTeam US and/or it's Assigns(“Quotient Industrial Capital LLC”) to request references from the bank, attorney and accountant relationships listed on this application. I hereby authorize the bank, attorney and accountant relationships listed on this application to fully respond to reference requests from Quotient Industrial Capital LLC and/or it's Assigns.

In connection with this application to FundingTeam US and/or it's Assigns (“Quotient Industrial Capital LLC”), I authorize FundtingTeam to obtain background reports on the Executive Officers listed on this application. Such reports may include, but are not limited to, information as to character, general reputation, personal characteristics, and mode of living; discerned through employment and education verification's; personal references and interviews; credit history based on reports from credit bureaus; driving records; workers’ compensation records; and to the extent permitted by law, social security number traces; criminal and civil history/records; and other public records. FundingTeam subscribes to the principles of equal opportunity and does not consider race, gender, religion or age when evaluating factoring applications.

I acknowledge that if I the entity for which this application is made chooses to enter into a factoring agreement with FundingTeam, the entity will be required to pay fees for UCC filings, application processing and UCC searches, and that the aggregate amount of these fees will be $500.

All information and documentation received by FundingTeam American Capital will only be used to evaluate this application, will not be used for any other purpose and will be safeguarded to preserve its privacy.

I certify that all information set forth throughout this application and on all documents provided in connection herewith is true and correct and not misleading. I understand that it is a crime to make false or misleading statements on a financial application.