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Company Information:

Company Name:

Representative:

Address:

City:

State:

Zip:

Phone:

Fax:

Email:

Federal ID No.:

Primary Business:

Years in Business:

Products and Services Offered (check all that apply)

Factoring

Asset Based Lending

Equipment Leasing

Bank Loans

Investment Banking

Venture Capital

Other Commercial Finance (describe):

Mortgages

Consumer Finance

SBA Packaging

Consulting (describe):

Professional (describe):

Other (describe):

Percent of time currently spent on factoring: %

Professional References

Reference Name:

Phone:

Relationship:

Reference Name:

Phone:

Relationship:

Reference Name:

Phone:

Relationship:

Professional Associations and Positions Held (include dates)
Association:

Date:

Position:

Association:

Date:

Position:

Association:

Date:

Position:

I acknowledge the above information to be accurate to the best of my knowledge. I hereby authorize Riviera Finance to investigate my references, prior employers, and other matters related to my qualifications as an Independent Representative. I authorize Riviera Finance to request and obtain a consumer credit report. If such a report is obtained, I understand that I have the right to receive a copy.

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