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General Information

Legal Business Name*

DBA*

State Tax ID Number*

Federal Tax ID Number*

Contact Number*

Street Address*

City*

State

ZIP*

General Nature of Business*

General Information Continued

First Name*

Last Name*

Email*

Phone*

Loan Request Information

Amount Requested $*

Minumum Amount Needed*

Describe the Type of Loan, Reason for your Loan and Use of Funds Requested - (Be Specific)*

Borrower Information

Total Assets $

Total Liabilities $

Net Worth $

Revenue Gross 2019 $

Ownership*

Revenue Gross: $

2016

2017

2018

YTD 2019: $

Business Information

Any Open or Old Tax Lien(s): $

Business Inception Date

No. Of Employees

Bradstreet #

Applicant Information

Applicant's Company Title

Cell Phone*

Applicant's Email*

Home Address

City

State

Social Security Number

Date of Birth

Zip

Applicant Information Cont.

Ownership %

Total Household Income (yearly): $

Total Household Assets: $

Total Household Liabilities: $

Marital Status

Co-Applicant

First Name

Last Name

Company Title

Cell Phone

Email Address

Home Address

City

State

Co-Applicant Continued

Ownership %

Date of Birth

Social Security Number

Total Assets: $

Total Liabilities: $

Marital Status

Banking Information #1

Bank/Institution

Account #

Account Type

Average Monthly Deposits: $

Current Balance: $

Contact Name

Date Opened

Phone

Banking Information #2

Bank/Institution

Account #

Account Type

Average Monthly Deposits: $

Current Balance: $

Contact Name

Date Opened

Phone

Real Estate Owned

Value of Resitional Real Estate Owned (total of all combined if more than one)

Mortgage Balance(s) on Residential Real Estate

Value of Commercial Real Estate Owned (total of all combined if more than one)

Mortgage Balance(s) on Commercial Real Estate

Landlord Information

Landlord Holder Name

Landlord Phone Number

How many years remain on Lease

Business Equipment

Do you Plan to purchase Equipment?

Do you Plan to purchase Equipment? Yes
No

If Yes, type:

Vendor Name

Vendor Phone #

Contact Person

Receivables & Purchases

Total Recievalbes $

Purchase Orders $

Have you received PO financing previously?

Have you received PO financing previously? Yes
No

If yes, who was the lender?

Merchant Account

Average Monthly Credit Card Volume (VISA/MasterCard): $

How many Merchant/Credit Card Accounts?

Merchant/Credit Card Processing Info: Processor:

Contact #

Terminal Type

% Cards Swiped:

Merchant Information

% Manually Keyed

% Phone/Mail

% Order

% Internet

Do you have any existing 'cash advances' and/or bank statement loans?

Do you have any existing 'cash advances' and/or bank statement loans? Yes
No

If so, With whom?

Trade Reference(s)

Company Name

Account #

Phone Number

Open Date

High Credit

Current balance

Contact Name

Trade Reference #2

Company Name

Account #

Phone Number

Open Date

High Credit

Current Balance

Contact Name

Trade Reference #3

Company Name

Account #

Phone Number

Open Date

High Credit

Current Balanace

Contact Name

Credit Evaluation

Do you know your personal credit score?

If so, what is your score?

Do you know if you have a D&B Business Credit File?

Do you know if you have a D&B Business Credit File? Yes
No

Do you know your D&B Paydex Score?

Do you have any UCC Lien Filings?

Do you have any UCC Lien Filings? Yes
No

If so, amount?

What is the UCC Filing on?

Do you have any existing Credit Lines?

Do you have any existing Credit Lines? Yes
No

If so, Balance?

With Who?

Miscellaneous Information

Do you have any Federal & State Taxes past due?

Do you have any Federal & State Taxes past due? Yes

If so, how much in Federal

State

Are you currently under the protection of the United States Bankruptcy Laws?

Are you currently under the protection of the United States Bankruptcy Laws? Yes
No

Have you been turned down previously? (This information is critical in determining what issues that need to be overcome)

Have you been turned down previously? (This information is critical in determining what issues that need to be overcome) Yes
No

By Whom and Reason(s):

Are you currently working with any lender, consultant or broker on this transaction?

Are you currently working with any lender, consultant or broker on this transaction? Yes
No

If yes, who:

Agreement

I/We completed an application containing various information and certify that all of the information is true and complete. I authorize the lender to investigate my credit worthiness and verify any information provided on my/our application and other related documents.

Business Name

Name

Title

Date

Authorization To Obtain Credit Information

I / We represent and warrant that the information provided in this credit application is complete, accurate and true. Each individual signing below also requests and authorizes any lenders or funding source which may be utilized (collectively referred to as “Lenders”) to obtain information from the references listed above and obtain commercial and/or consumer credit histories that will be ongoing and relate not only to the evaluation of the business credit requested, but also for purposes of reviewing the account, increasing the credit line on the account (if applicable), taking collection action on the account, and for any other legitimate purpose associated with the account as may be needed.

A facsimile, electronic or other copy of this signed authorization shall be as valid as the original.

Applicant's Printed Name

Date

Thank You for your submission

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