[Creditor/Lender Name]
[Address]
[Phone] [Email] [Website]
Application Date: [MM/DD/YYYY]
Application Type: [Individual / Joint / Business]
Primary Bank: [Name] Branch: [Location] Account Type(s): [Checking/Savings/Operating] Account Number (last 4): [XXXX]
Bank Contact: [Name/Phone/Email]
Record bank verification contacts and outcomes:
Date | Contact Method | Person Reached | Information Confirmed | Outcome |
[MM/DD/YYYY] | [Call/Email/Portal] | [Name/Dept] | [Account standing/relationship/other] | [Verified/Pending/Unable] |
[MM/DD/YYYY] | [Call/Email/Portal] | [Name/Dept] | [Account standing/relationship/other] | [Verified/Pending/Unable] |
Date | Contact Method | Person Reached | Information Confirmed | Outcome |
[MM/DD/YYYY] | [Call/Email/Portal] | [Name/Dept] | [Account standing/relationship/other] | [Verified/Pending/Unable] |
[MM/DD/YYYY] | [Call/Email/Portal] | [Name/Dept] | [Account standing/relationship/other] | [Verified/Pending/Unable] |
Date
Contact Method
Person Reached
Information Confirmed
Outcome
[MM/DD/YYYY]
[Call/Email/Portal]
[Name/Dept]
[Account standing/relationship/other]
[Verified/Pending/Unable]
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, Phone, Email]
3. 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]
4. Employment or Business Profile
For individuals: Employer: [Name] Title: [Role] Start Date: [MM/YYYY] Monthly Gross Income: [Amount] Other Income: [Source/Amount]
For businesses: Formation Date: [MM/DD/YYYY] Industry/NAICS: [Code/Description] Employees: [#] Annual Revenue: [Amount] YTD Revenue: [Amount] Owners and %: [List]
5. 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]
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/AP Aging: [Current/30/60/90+] Debt Schedule: [Lender, balance, rate, maturity]
7. Data Security and Consent Acknowledgment
Submission Method: [Secure portal/encrypted email/in-person/other]
Authorized Use of Data: [Underwriting, fraud prevention, account servicing, collections] consistent with applicable law.
Applicant acknowledges that access to submitted data is limited to [Authorized Personnel/Service Providers] for the purposes stated.
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 agrees to notify the creditor of any material changes to the information provided.
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 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
Supporting Documents: [Government ID, proof of address, formation documents, ownership list, financial statements, AR/AP aging, other]
12. Signatures
Applicant/Authorized Signer: [Full Name] Title (if business): [Title]
Bank Verification Contact (optional): [Full Name] Title: [Title]
Date | Contact Method | Person Reached | Information Confirmed | Outcome |
[MM/DD/YYYY] | [Call/Email/Portal] | [Name/Dept] | [Account standing/relationship/other] | [Verified/Pending/Unable] |
[MM/DD/YYYY] | [Call/Email/Portal] | [Name/Dept] | [Account standing/relationship/other] | [Verified/Pending/Unable] |