[Creditor/Lender Name]
[Address]
[Phone] [Email] [Website]
Application Date: [MM/DD/YYYY]
Application Type: [Individual / Joint / Business]
1. 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 of Credit: [Working capital/equipment/inventory/other]
2. Applicant Profile
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: [URL]
For individuals: Employer: [Name] Title: [Role] Start Date: [MM/YYYY] Monthly Gross Income: [Amount]
For businesses: Primary Contact: [Name, Title, Email, Phone] Annual Revenue: [Amount] YTD Revenue: [Amount] Employees: [#] Owners and %: [List]
3. Trade Reference Comparison
List trade references in a comparison format:
Reference | Contact | Account # | Terms | Avg. Monthly Balance |
[Company 1] | [Name/Phone/Email] | [Account #] | [Net Terms/Other] | $[Amount] |
[Company 2] | [Name/Phone/Email] | [Account #] | [Net Terms/Other] | $[Amount] |
[Company 3] | [Name/Phone/Email] | [Account #] | [Net Terms/Other] | $[Amount] |
Reference | Contact | Account # | Terms | Avg. Monthly Balance |
[Company 1] | [Name/Phone/Email] | [Account #] | [Net Terms/Other] | $[Amount] |
[Company 2] | [Name/Phone/Email] | [Account #] | [Net Terms/Other] | $[Amount] |
[Company 3] | [Name/Phone/Email] | [Account #] | [Net Terms/Other] | $[Amount] |
Reference
Contact
Account #
Terms
Avg. Monthly Balance
[Company 1]
[Name/Phone/Email]
[Account #]
[Net Terms/Other]
$[Amount]
[Company 2]
[Company 3]
Primary Bank: [Name] Branch: [Location]
Account Type(s): [Checking/Savings/Operating] Account Number (last 4): [XXXX]
Bank Contact: [Name/Phone/Email]
5. Financial Snapshot
For individuals: Housing Payment: [Amount] Own/Rent: [Own/Rent] Assets: [Summary] Liabilities: [Summary]
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+]
Debt Schedule Detail: [Lender, balance, rate, maturity, collateral (if any)]
6. Collateral or Equipment Addendum (Optional)
Collateral Type: [Equipment/Inventory/Receivables/Other]
Collateral Description: [Serial numbers/SKU categories/portfolio description]
Collateral Location: [Address]
7. Authorized Users and Purchasing Controls
Authorized User 1: [Name, Title, Phone, Email] Authority: [Place orders/approve credit changes/receive statements]
Authorized User 2: [Name, Title, Phone, Email] Authority: [Place orders/approve credit changes/receive statements]
Order Method: [Purchase Order/Portal/Email/Other] Purchase Order Prefix (optional): [Prefix]
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 and to contact banks and trade references for verification now and in the future 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.
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. Terms and Conditions Acknowledgment
Account Terms Delivery Method: [Link/Email/Printed Copy]
Applicant acknowledges receipt or availability of the account terms and agrees to be bound upon acceptance of credit.
11. Attachments Checklist
Supporting Documents: [Government ID (if individual), formation documents (if business), financial statements, AR/AP aging, debt schedule, other]
12. Signatures
Applicant/Authorized Signer: [Full Name] Title (if business): [Title]
Guarantor (if required): [Full Name]
Reference | Contact | Account # | Terms | Avg. Monthly Balance |
[Company 1] | [Name/Phone/Email] | [Account #] | [Net Terms/Other] | $[Amount] |
[Company 2] | [Name/Phone/Email] | [Account #] | [Net Terms/Other] | $[Amount] |
[Company 3] | [Name/Phone/Email] | [Account #] | [Net Terms/Other] | $[Amount] |