[Creditor/Lender Name]
[Address]
[Phone] [Email] [Website]
Application Date: [MM/DD/YYYY]
Application Type: [Individual / Joint / Business]
1. Application Snapshot
Requested Credit Type: [Revolving/Net Terms/Installment/Lease/Other]
Requested Credit Limit/Amount: [Amount]
Requested Terms: [Net 30 / APR % / Tenor / Other]
Primary Account Purpose: [Working capital/equipment/inventory/other]
Primary Decision Contact: [Name, Title, Phone, Email]
2. Applicant Identity
Legal Name: [First Middle Last or Business Legal Name]
DBA (if any): [Name]
Entity Type (for business): [LLC/Corp/Sole Prop/Partnership/Nonprofit]
Tax ID / SSN / EIN: [Number]
Date of Birth (for individual): [MM/DD/YYYY]
Incorporation/Formation Date (for business): [MM/DD/YYYY]
Primary Address: [Street, City, State/Province, Postal Code, Country]
Phone: [Number]
Email: [Address]
Website (if any): [URL]
3. Employment or Business Profile
For individuals: Employer: [Name] Title: [Role] Start Date: [MM/YYYY] Monthly Gross Income: [Amount] Other Income: [Source/Amount]
For businesses: Primary Contact: [Name, Title, Email, Phone] Industry/NAICS: [Code/Description] Employees: [#] Annual Revenue (last fiscal year): [Amount] Current Year YTD Revenue: [Amount] Ownership Structure: [List owners and %]
4. Banking and Trade References
Primary Bank: [Name] Branch: [Location] Account Type(s): [Checking/Savings/Operating] Account Number (last 4): [XXXX] Bank Contact: [Name/Phone/Email]
Trade Reference 1: [Company, Contact, Phone/Email, Account #, Average Monthly Balance/Terms]
Trade Reference 2: [Company, Contact, Phone/Email, Account #, Average Monthly Balance/Terms]
Trade Reference 3: [Company, Contact, Phone/Email, Account #, Average Monthly Balance/Terms]
5. Financial Position
For individuals: Monthly Housing Payment: [Amount] Own/Rent: [Own/Rent] Assets: [Summary and estimated values] Liabilities: [Summary and balances] Supporting Documents: [Pay stubs/tax return/other]
For businesses: Fiscal Year Financials: [Attached Y/N] Interim Financials (YTD): [Attached Y/N] Accounts Receivable Aging: [Current/30/60/90+] Accounts Payable Aging: [Current/30/60/90+] Existing Debt Schedule: [Lender, balance, rate, maturity]
6. Certifications and Consents
By signing, the undersigned certifies that the information provided is true, correct, and complete and authorizes the creditor to obtain consumer and/or commercial credit reports, bank references, and trade references for account review, maintenance, or collection.
The undersigned authorizes verification of employment or business information and contact with references and financial institutions.
The applicant authorizes sharing of application data internally and with service providers for underwriting, fraud prevention, and account servicing consistent with applicable law.
The applicant agrees to notify the creditor of any material changes to the information provided.
7. Terms and Conditions Acknowledgment
If approved, the account will be governed by the creditor’s credit agreement or account terms, including payment obligations, late fees, finance charges, and remedies upon default.
Applicant acknowledges receipt or availability of those terms and agrees to be bound upon acceptance of credit.
8. Beneficial Ownership and Control Persons (Business Applicants)
Complete the beneficial ownership and control persons matrix:
Name | Role | Ownership % | Residential Address | ID Type/Last 4 |
[Name] | [Owner/Officer/Control Person] | [%] | [Address] | [Type/XXXX] |
[Name] | [Owner/Officer/Control Person] | [%] | [Address] | [Type/XXXX] |
[Name] | [Owner/Officer/Control Person] | [%] | [Address] | [Type/XXXX] |
Name | Role | Ownership % | Residential Address | ID Type/Last 4 |
[Name] | [Owner/Officer/Control Person] | [%] | [Address] | [Type/XXXX] |
[Name] | [Owner/Officer/Control Person] | [%] | [Address] | [Type/XXXX] |
[Name] | [Owner/Officer/Control Person] | [%] | [Address] | [Type/XXXX] |
Name
Role
Ownership %
Residential Address
ID Type/Last 4
[Name]
[Owner/Officer/Control Person]
[%]
[Type/XXXX]
9. Verification and Screening Module
Identity Verification Method: [Document verification / knowledge-based / in-person / other]
Business Verification Method: [Formation records / good standing / website verification / other]
Screening Notes: [Sanctions/AML screening results and date]
10. Personal Guaranty (If Required)
In consideration of the extension of credit to the applicant business, the undersigned guarantor(s) unconditionally guarantee payment and performance of all obligations, including costs of collection and reasonable attorney’s fees, under the account terms.
This is a continuing guaranty and may be revoked in writing prospectively as to future credit only.
Guarantor Name: [Full Name] Home Address: [Address] SSN/Tax ID (last 4): [XXXX]
Signature: __________________________ Date: __________
11. Attachments Checklist
Individuals: [Government ID, proof of address, income verification, other]
Businesses: [Formation documents, good standing certificate, ownership list, financial statements, AR/AP aging, tax returns (if requested), resale/exemption certificates (if relevant)]
12. Signatures
Applicant/Authorized Signer: [Full Name] Title (if business): [Title]
Co-Applicant (if any): [Full Name]
Name | Role | Ownership % | Residential Address | ID Type/Last 4 |
[Name] | [Owner/Officer/Control Person] | [%] | [Address] | [Type/XXXX] |
[Name] | [Owner/Officer/Control Person] | [%] | [Address] | [Type/XXXX] |
[Name] | [Owner/Officer/Control Person] | [%] | [Address] | [Type/XXXX] |
