[Creditor/Lender Name]
[Address]
[Phone] [Email] [Website]
Application Date: [MM/DD/YYYY]
Application Type: [Individual / Joint / Business]
Business Legal Name: [Business Legal Name]
DBA (if any): [Name]
Entity Type: [LLC/Corp/Sole Prop/Partnership/Nonprofit]
Formation Date: [MM/DD/YYYY]
EIN/Tax ID: [Number]
Primary Address: [Street, City, State/Province, Postal Code, Country]
Primary Contact: [Name, Title, Phone, Email]
Billing Contact: [Name, Title, Phone, Email]
2. Authorized Users and Signing Authority
List authorized users and define their authority levels:
Name | Role/Title | Order Authority | Change Authority | Contact |
[Name 1] | [Title] | [Place orders Y/N] | [Limit/terms changes Y/N] | [Phone/Email] |
[Name 2] | [Title] | [Place orders Y/N] | [Limit/terms changes Y/N] | [Phone/Email] |
[Name 3] | [Title] | [Place orders Y/N] | [Limit/terms changes Y/N] | [Phone/Email] |
Name | Role/Title | Order Authority | Change Authority | Contact |
[Name 1] | [Title] | [Place orders Y/N] | [Limit/terms changes Y/N] | [Phone/Email] |
[Name 2] | [Title] | [Place orders Y/N] | [Limit/terms changes Y/N] | [Phone/Email] |
[Name 3] | [Title] | [Place orders Y/N] | [Limit/terms changes Y/N] | [Phone/Email] |
Name
Role/Title
Order Authority
Change Authority
Contact
[Name 1]
[Title]
[Place orders Y/N]
[Limit/terms changes Y/N]
[Phone/Email]
[Name 2]
[Name 3]
3. Applicant Identity (Individual Applicants or Control Person)
Full Legal Name: [First Middle Last]
Date of Birth: [MM/DD/YYYY]
SSN/Tax ID (last 4): [XXXX]
Home Address: [Street, City, State/Province, Postal Code, Country]
Phone: [Number] Email: [Address]
4. Credit Request
Requested Credit Type: [Revolving/Net Terms/Installment/Lease/Other]
Requested Credit Limit/Amount: [Amount]
Requested Terms: [Net 30/APR %/Tenor/Other]
Primary Use: [Working capital/equipment/inventory/other]
5. Banking and Payment Setup
Primary Bank: [Name] Branch: [Location] Account Type: [Checking/Savings/Operating] Account Number (last 4): [XXXX]
Bank Contact: [Name/Phone/Email]
Preferred Payment Method: [ACH/Check/Wire/Portal/Other]
ACH Authorization (optional): [Authorized Y/N] ACH Contact: [Name/Email/Phone]
6. Trade References
Reference 1: [Company, Contact, Phone/Email, Account #, Average Monthly Balance/Terms]
Reference 2: [Company, Contact, Phone/Email, Account #, Average Monthly Balance/Terms]
Reference 3: [Company, Contact, Phone/Email, Account #, Average Monthly Balance/Terms]
Annual Revenue (last fiscal year): $[Amount] Current Year YTD Revenue: $[Amount] Employees: [#]
Financial Statements: [Attached Y/N] AR/AP Aging: [Attached Y/N] Existing Debt Summary: [Lender, balance, rate, maturity]
8. Certifications and Consents
The undersigned certifies the information provided is true, correct, and complete and authorizes the creditor to obtain credit reports and to contact banks and trade references for verification for account review, maintenance, or collection.
The applicant authorizes internal and service-provider processing 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.
9. Terms and Conditions Acknowledgment
Account Terms Delivery: [Link/Email/Printed Copy]
Applicant acknowledges receipt or availability of the account terms and agrees to be bound upon acceptance of credit.
10. Personal Guaranty (If Required)
Guarantor Name: [Full Name] Home Address: [Address] SSN/Tax ID (last 4): [XXXX]
Signature: __________________________ Date: __________
11. Attachments Checklist
Business Documents: [Formation documents, ownership list, financials, AR/AP aging, tax returns (if requested), other]
Identity Documents (if requested): [Government ID, proof of address, other]
12. Signatures
Business Applicant Authorized Signer: [Full Name] Title: [Title]
Account Operations Signer (optional): [Full Name] Title: [Title]
Name | Role/Title | Order Authority | Change Authority | Contact |
[Name 1] | [Title] | [Place orders Y/N] | [Limit/terms changes Y/N] | [Phone/Email] |
[Name 2] | [Title] | [Place orders Y/N] | [Limit/terms changes Y/N] | [Phone/Email] |
[Name 3] | [Title] | [Place orders Y/N] | [Limit/terms changes Y/N] | [Phone/Email] |