SURVEY FORM

1. Please fill out the form below.
   

   		
        First name 
   
         Last name 
   
             Phone 
   
               Fax 
   
      Organization 
   
    Street address 
   
   Address (cont.) 
   
              City 
   
    State/Province 
   
   Zip/Postal code 
   
           Country 
   
        Work Phone 
   
            E-Mail 
   
   	

2. What type of financing are you interested in?

   Factoring A/R Financing Other
   

3. Do you have a unique financial situation you would like to discuss?

   Yes No
   
   

4. If so, what can you tell us about the challenges now facing your company?