Main St. Factors Credit Application
	Delivery Locations:
Company Name_______________________________	___________________
DBA Name__________________________________	___________________
Billing Address________________________________	___________________
City, State, Zip________________________________	___________________
Phone__(___)__________Fax_(___)_____________	___________________
Contact____________________________________	___________________
Owner_____________________________________	___________________
Fed Tax ID/SSN_______________________________	___________________
Credit Information
Who will be responsible for Payment?    Name___________________________________ Title____________________   Phone____________________
Is outside agency responsible? Name of Agency__________________________________ Mailing Address____________________________________________________ Person Handling Acct.____________________________Phone_________________ Are you listed with Dun & Bradstreet or in the Lyon Red Book?_________________________

List five (5) credit references and one bank:
Name/Address	Phone	Contact	Account Number
1.____________________ _____________________	_____________ _____________	_____________ _____________	_____________ _____________
2.____________________ _____________________	_____________ _____________	_____________ _____________	_____________ _____________
3.____________________ _____________________	_____________ _____________	_____________ _____________	_____________ _____________
4.____________________ _____________________	_____________ _____________	_____________ _____________	_____________ _____________
5.____________________ _____________________	_____________ _____________	_____________ _____________	_____________ _____________
Bank__________________ _____________________	_____________ _____________	_____________ _____________	_____________ _____________
Please Attach Financial Statement     1) Company and/or     2) Personal
Return to: Main St. Factors                 P.O. Box 2084                 Tupelo, Ms 38803                 Phone:(662)680-4600 Fax:(662)680-4550		Authorization for release of information. Signature__________________________ Title______________________________