“FACTORING SERVICE
PRE-APPROVAL FORM”

Please complete this simple form to begin the approval process from Praxis factoring service.
Call (484) 537-0600 x103 to speak to Jay Starr, or email him
at info@praxiscapital.com
Required Items are marked with *

	*COMPANY NAME:
	STATE IN WHICH COMPANY IS INCORPORATED:
	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
	*CONTACT NAME:
	*CONTACT PHONE NUMBER:
	*CONTACT EMAIL ADDRESS:
	CURRENT DOLLAR VALUE OF ACCOUNTS RECEIVABLE OUTSTANDING:
	PROMOTION CODE:
	Thank you for your interest in the factoring service of Praxis Capital.