Application Step 1 of 5 20% OrganizationEXACT LEGAL COMPANY NAMEAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country CONTACT NAMECOUNTYSTATE OF REGISTRATIONAKALAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYWHEN REGISTEREDBUSINESS DESCRIPTION Client Profile FormD/B/A (IF APPLIC)EMAIL ADDRESSBEST CONTACT #FAXORGANIZATION TYPE CORP LLC PARTNERSHIP SOLE PROPRIETORSHIP TAX ID # (MANDATORY)* Officers - Business InformationPRESIDENTVICE PRES.ACCOUNTANTPHONEATTORNEYPHONE Receivable & Contract InformationAVERAGE SIZE OF INVOICEESTIMATED MONTHLY BILLING AMOUNT?ARE COMPANY TAXES UP TO DATE? Yes No IF NO, HOW MUCH DUE?PAYMENT PLAN IN PLACE? Yes No ARE RECEIVABLES PLEDGED AS SECURITY ELSEWHERE? Yes No IF YES, WITH WHOM? Origination AgreementThe undersigned, at the initiation of its relationship with Millennium Funding, a Canfield Capital Management, LLC company "MILLENNIUM" warrants that there are no Local, State or Federal Tax Liens, or previous UCC filings against its current or future accounts receivable, and shall pay a deposit of $500 which deposit shall be applied to the cost of filing UCC-1 financing statement(s) or any other public records required by "MILLENNIUM" to comply with applicable state or federal laws. The undersigned further grants "MILLENNIUM" authority to effectuate corporate and personal credit investigations as well as sign it's name on UCC-1 Financing Statement(s) in order to effect filings according to the tenor of any and all current and future Purchase and Sale agreements, and/or any loan documents that may be executed by the parties or for any debtor notifications necessary to inform undersigned's account debtors of any and all assignments. Undersigned further agrees that it will not further encumber the assets set forth in the Purchase & Sale Agreement or other Security Agreement or increase the indebtedness thereon, or transfer or assign said assets except in the ordinary course of business. In addition, the undersigned shall be responsible to reimburse "MILLENNIUM" for expenses actually incurred on behalf of the undersigned including, but not limited to Federal Express charges, credit investigations, lien searches, and periodic tax lien searches.; "MILLENNIUM” shall be authorized to deduct all such expenses from any moneys it shall be holding to the credit of the undersigned.Signature*The Undersigned warrants that the above information is true and correct. All information and documentation will be held in the strictest confidence by Millennium Funding and will not be used for any other purpose other than to determine eligibility for funding. Printed Name*Date Current Accounts Receivable Aging ReportIn order to receive a NO OBLIGATION proposal please upload a current accounts receivable aging report and this completed client profile form.May we contact you in the future?*YesNoEmailThis field is for validation purposes and should be left unchanged.