[Creditor/Lender Name]
[Address]
[Phone] [Email] [Website]
Application Date: [MM/DD/YYYY]
Application Type: [Individual / Joint / Business]
Legal Name: [First Middle Last or Business Legal Name]
DBA (if any): [Name]
Tax ID / SSN / EIN: [Number]
Primary Address: [Street, City, State/Province, Postal Code, Country]
Phone: [Number] Email: [Address]
Authorized Contact (business): [Name, Title, Phone, Email]
2. Requested Credit Terms Worksheet
Complete the requested terms worksheet:
Credit Type | Requested Limit/Amount | Requested Terms | Intended Use | Start Date |
[Revolving/Net Terms/Installment/Lease/Other] | $[Amount] | [Net 30/APR/Tenor/Other] | [Use] | [MM/DD/YYYY] |
[Optional Second Product] | $[Amount] | [Net 30/APR/Tenor/Other] | [Use] | [MM/DD/YYYY] |
Credit Type | Requested Limit/Amount | Requested Terms | Intended Use | Start Date |
[Revolving/Net Terms/Installment/Lease/Other] | $[Amount] | [Net 30/APR/Tenor/Other] | [Use] | [MM/DD/YYYY] |
[Optional Second Product] | $[Amount] | [Net 30/APR/Tenor/Other] | [Use] | [MM/DD/YYYY] |
Credit Type
Requested Limit/Amount
Requested Terms
Intended Use
Start Date
[Revolving/Net Terms/Installment/Lease/Other]
$[Amount]
[Net 30/APR/Tenor/Other]
[Use]
[MM/DD/YYYY]
[Optional Second Product]
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: Entity Type: [LLC/Corp/Sole Prop/Partnership/Nonprofit] Formation Date: [MM/DD/YYYY] Industry/NAICS: [Code/Description] Employees: [#] Annual Revenue: [Amount] YTD Revenue: [Amount]
Primary Bank: [Name] Branch: [Location] Account Type(s): [Checking/Savings/Operating] Account Number (last 4): [XXXX]
Bank Contact: [Name/Phone/Email]
Secondary Bank (if any): [Name/Branch/Account Type/Last 4/Contact]
5. Trade and Credit 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]
For individuals: Housing Payment: [Amount] Own/Rent: [Own/Rent] Assets: [Summary] Liabilities: [Summary] Supporting Documents: [Pay stubs/tax return/other]
For businesses: Fiscal Year Financials: [Attached Y/N] Interim Financials (YTD): [Attached Y/N] AR Aging: [Current/30/60/90+] AP Aging: [Current/30/60/90+] Existing Debt: [Lender, balance, rate, maturity]
7. Account Delivery and Communication Preferences
Statements and Notices to: [Email/Physical Address/Both]
Billing Contact: [Name, Title, Email, Phone]
Order Contact (if different): [Name, Title, Email, Phone]
Preferred Language (optional): [Language]
8. 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 now and in the future for account review, maintenance, or collection.
The undersigned authorizes verification of employment or business information and contact with references and financial institutions.
Data Sharing Scope: [Internal review, service providers, fraud prevention, account servicing] consistent with applicable law.
9. Personal Guaranty (If Required)
Guarantor Name: [Full Name] Home Address: [Address] SSN/Tax ID (last 4): [XXXX]
Signature: __________________________ Date: __________
10. 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.
11. Attachments Checklist
Individuals: [Government ID, proof of address, income verification, other]
Businesses: [Formation documents, ownership list, financial statements, AR/AP aging, debt schedule, other]
12. Signatures
Applicant/Authorized Signer: [Full Name] Title (if business): [Title]
Authorized Secondary Signer (optional): [Full Name] Title: [Title]
Credit Type | Requested Limit/Amount | Requested Terms | Intended Use | Start Date |
[Revolving/Net Terms/Installment/Lease/Other] | $[Amount] | [Net 30/APR/Tenor/Other] | [Use] | [MM/DD/YYYY] |
[Optional Second Product] | $[Amount] | [Net 30/APR/Tenor/Other] | [Use] | [MM/DD/YYYY] |