[Creditor/Lender Name]
[Address]
[Phone] [Email] [Website]
Application Date: [MM/DD/YYYY]
Application Type: [Individual / Joint / Business]
1. Compliance and Disclosures
Applicant Screening Statement: [Not a prohibited party / no unlawful use / other]
KYC/KYB Documents Provided: [ID, business registration, beneficial ownership, other]
Privacy Notice Delivery Method: [Link/Email/Printed Copy]
Adverse Decision Contact (if needed): [Name, Email, Phone]
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]
Primary Address: [Street, City, State/Province, Postal Code, Country]
Phone: [Number] Email: [Address] Website (if any): [URL]
Primary Contact: [Name, Title, Email, Phone]
For individuals: Monthly Income: [Amount] Housing Payment: [Amount] Assets: [Summary] Liabilities: [Summary]
For businesses: Annual Revenue (last fiscal year): [Amount] YTD Revenue: [Amount] Employees: [#]
Financial Statements: [Attached Y/N] AR/AP Aging: [Attached Y/N] Debt Summary: [Lender, balance, rate, maturity]
4. Credit Request
Requested Credit Type: [Revolving/Net Terms/Installment/Lease/Other]
Requested Credit Limit/Amount: [Amount]
Requested Terms: [Net 30/APR %/Tenor/Other]
Intended Use: [Working capital/equipment/inventory/other]
5. Document Intake Tracker
Track submitted documents using the intake tracker:
Document | Required | Provided | Date Received | Notes/Link |
[Government ID/Authorized Signer ID] | [Y/N] | [Y/N] | [MM/DD/YYYY] | [Link/Notes] |
[Formation Documents/Registration] | [Y/N] | [Y/N] | [MM/DD/YYYY] | [Link/Notes] |
[Financial Statements] | [Y/N] | [Y/N] | [MM/DD/YYYY] | [Link/Notes] |
[AR/AP Aging or Bank Statements] | [Y/N] | [Y/N] | [MM/DD/YYYY] | [Link/Notes] |
Document | Required | Provided | Date Received | Notes/Link |
[Government ID/Authorized Signer ID] | [Y/N] | [Y/N] | [MM/DD/YYYY] | [Link/Notes] |
[Formation Documents/Registration] | [Y/N] | [Y/N] | [MM/DD/YYYY] | [Link/Notes] |
[Financial Statements] | [Y/N] | [Y/N] | [MM/DD/YYYY] | [Link/Notes] |
[AR/AP Aging or Bank Statements] | [Y/N] | [Y/N] | [MM/DD/YYYY] | [Link/Notes] |
Document
Required
Provided
Date Received
Notes/Link
[Government ID/Authorized Signer ID]
[Y/N]
[MM/DD/YYYY]
[Link/Notes]
[Formation Documents/Registration]
[Financial Statements]
[AR/AP Aging or Bank Statements]
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]
Primary Bank: [Name] Branch: [Location] Account Type(s): [Checking/Savings/Operating] Account Number (last 4): [XXXX]
Bank Contact: [Name/Phone/Email]
8. Authorized Users / Signers
Authorized User 1: [Name, Title, Phone, Email] Permissions: [Orders/Statements/Account Changes]
Authorized User 2: [Name, Title, Phone, Email] Permissions: [Orders/Statements/Account Changes]
9. Personal Guaranty (If Required for Business Credit)
In consideration of the extension of credit to the applicant business, the undersigned guarantor(s) unconditionally guarantee payment and performance of all obligations under the account terms.
Guarantor Name: [Full Name] Home Address: [Address] SSN/Tax ID (last 4): [XXXX]
Signature: __________________________ Date: __________
10. Certifications and Consents
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 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.
11. Terms and Conditions Acknowledgment
If approved, the account will be governed by the creditor’s 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.
12. Signatures
Applicant/Authorized Signer: [Full Name] Title (if business): [Title]
Compliance Contact (optional): [Full Name] Title: [Title]
Document | Required | Provided | Date Received | Notes/Link |
[Government ID/Authorized Signer ID] | [Y/N] | [Y/N] | [MM/DD/YYYY] | [Link/Notes] |
[Formation Documents/Registration] | [Y/N] | [Y/N] | [MM/DD/YYYY] | [Link/Notes] |
[Financial Statements] | [Y/N] | [Y/N] | [MM/DD/YYYY] | [Link/Notes] |
[AR/AP Aging or Bank Statements] | [Y/N] | [Y/N] | [MM/DD/YYYY] | [Link/Notes] |