Application form V6

Business

Full legal name of business:

ABN/ACN:

Type of entity:

State of incorporation:

Other trade name(s):

Prior business name(s) in past 5 years:

Address:

Street:

Suburb:

State:

Postcode:

Tel: office:

Website:

Date established:

Industry:

Describe your business:

Number of employees:

Owners/Officers

Please indicate number of owners here:

Owner 1

Title:

First Name:

Last Name:

Address:

Street:

Suburb:

State:

Postcode:

Tel: mobile:

Tel: home:

Primary email address:

Drivers licence no:

Date of birth:

Company position:

Ownership %:

Beneficial or non-beneficial (eg as trustee):

Owner 2

Title:

First Name:

Last Name:

Address:

Street:

Suburb:

State:

Postcode:

Tel: mobile:

Tel: home:

Primary email address:

Drivers licence no:

Date of birth:

Company position:

Ownership %:

Beneficial or non-beneficial (eg as trustee):

Owner 3

Title:

First Name:

Last Name:

Address:

Street:

Suburb:

State:

Postcode:

Tel: mobile:

Tel: home:

Primary email address:

Drivers licence no:

Date of birth:

Company position:

Ownership %:

Beneficial or non-beneficial (eg as trustee):

Owner 4

Title:

First Name:

Last Name:

Address:

Street:

Suburb:

State:

Postcode:

Tel: mobile:

Tel: home:

Primary email address:

Drivers licence no:

Date of birth:

Company position:

Ownership %:

Beneficial or non-beneficial (eg as trustee):

If there are further owners, please add under Further Information

Bank details

Name of primary business bank:

Other bank if not listed above:

Number of years with this bank:

Address:

Street:

Suburb:

State:

Postcode:

Account name:

BSB:

Account number:

Total limit of all current credit facilities:

Average amount outstanding in last 30 days:

Collateral / security provided:

Any other bank or credit providers?:

Name of other bank or credit providers (if any):

Accounts receivable

Accounts receivable outstanding:

Average invoice amount:

Number of accounts:

Usual payment terms:

Names and your monthly sales of 5 largest customers:

Customer 1 Name:

Monthly Sales:

Customer 2 Name:

Monthly Sales:

Customer 3 Name:

Monthly Sales:

Customer 4 Name:

Monthly Sales:

Customer 5 Name:

Monthly Sales:

Debtor Information:

What discount, if any, do you give for early payment?

Do you sell on a sale/return/exchange basis?

Do you sell on consignment basis?

Do you invoice on a progress claim / milestone basis?

Do you have your debtors insured?

List any debtors who are also suppliers to your business:

Debtor 1:

Debtor 2:

Debtor 3:

Debtor 4:

If ‘Yes’ for any of the above, please provide the details in Section 7 - Further information.

External accountant's details and your accounting system:

Name of firm:

Length of business relationship - years:

Business Address:

Street:

Suburb:

State:

Postcode:

Accounting system used for your accounts:

Client Credit History:

Has a manager/receiver or liquidator ever been appointed?

Are there any unsatisfied judgement(s) entered in any court against the company, any of its officers or you?

Do you have any tax arrears? Do you or the company have arrangements with creditors, financiers or ATO?

Has the company, any of its officers or you ever become or been bankrupt or insolvent or assigned its/their estate/s for the benefit of creditors?

Is any legal action(s) pending?

Are you an undischarged bankrupt?

Are there any unsatisfied judgements??

If ‘Yes’ for any of the above, please provide the details in Section 7 - Further information.

Further information:

Please provide any other relevant information (if any):

Documentation:

Please click on the checkbox to attach documents

For the business:

Latest management accounts including aged accounts receivables and accounts payables

Last 2 years financial statements

Copy of your most recent bank statement

Latest ATO integrated client account statement

For each shareholder holding over 20% of the company's ordinary share capital:

Driver's licence or passport (certified copies)

Utility bill or bank statement dated within the last 3 months (certified copies)

Acceptance

I/(We) certify under penalty of perjury and obtaining money under false pretences that the information provided in this application is true and correct as of today's date and acknowledge my understanding that any intentional or negligent misrepresentation of the information contained in this application may result in civil liability and/or criminal penalties and liability for monetary damages to InvoiceX, its agents, successors and assigns or any other person who may suffer loss due to reliance upon any misrepresentation which I have made on this application.

I/(We) have read and agree to the Privacy Policy as stated in our website: www.allbridge.com.au/privacy-cookies/

Signatures

A

Signed:

Signatures will be carried out electronically once application has been reviewed

Print Full Name:

Position (Director/Secretary):

B

Signed:

Signatures will be carried out electronically once application has been reviewed

Print Full Name:

Position (Director/Secretary):