“INDEPENDENT REPRESENTATIVE
ONLINE APPLICATION FORM”

Call (484) 537-0600 x103 to speak to Jay Starr, or email him at info@praxiscapital.com

Required Items are marked with *

	*COMPANY NAME:
	YEARS ESTABLISHED:
	*REPRESENTATIVE:
	*EMAIL ADDRESS :
	*ADDRESS:
	*CITY: * STATE: * ZIP:
	*TELEPHONE: *FAX:
	FEDERAL TAX ID #:
	REPRESENTATIVE SSN #:
	DESCRIPTION OF PRIMARY BUSINESS:
	PRODUCTS/SERVICES OFFERED (CHECK ALL PERTAINING):
	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):
	PERCENTAGE OF TIME CURRENTLY SPENT ON FACTORING: %
	PROFESSIONAL REFERENCES:
	NAME:
	TELEPHONE:
	RELATIONSHIP:
	NAME:
	TELEPHONE:
	RELATIONSHIP:
	NAME:
	TELEPHONE:
	RELATIONSHIP:
	PROFESSIONAL ASSOCIATES AND POSITIONS HELD (DATES):
	1.
	2.
	I acknowledge the above information to be accurate to the best of my knowledge. I hereby authorize Praxis Capital, LP to investigate my references, prior employers and other matters related to my qualifications as an Independent Representative.
	ACCEPT DO NOT ACCEPT
	Thank you for your interest in the factoring service of Praxis Capital.