Full Name

Birth Date (MM/DD/YYYY)

Gender Male Female

Driver’s License

Home Telephone

Cellular Phone

Email

Home Address

Mailing Address

City

State

Zip Code

Marital Status Married Common Law Divorced Single

Social Security

Previous address (if less than 3 years at current address)

Do you rent or own your home Rent Own

How long at this address?

Current or most recent employer’s name

Employer’s telephone

Salary

How long were you employed/have been employed here

Will this business be a start up? YesNo

Is this an existing business? YesNo

This business have been operating full-time since (if applicable)

This business has been operating part-time since (if applicable)

This business will be a (check one) Proprietorship or Partnership Incorporation Non-Profit Limited Partnership Co-op

This business will be operating in the primary sector of (check one) Real Estate Agriculture Forestry Manufacturing Retail Service Tourism Wholesale Other

Business Number (if obtained)

Incorporation Number (if obtained)

Legal name of business is/will be

Physical address of business

City

State

Zip Code

Business Telephone

Business Fax

Email

Website

Mailing address of business (if different than above)

Loan Amount $

Loan Duration

Purpose of Loan

Has the borrower/spouse/common law party ever had an asset repossessed? Yes No

Has the borrower/spouse/common law party ever declared bankruptcy? Yes No

Is the borrower/spouse/common law party to any claim or lawsuit? Yes No

Does the borrower/spouse/common law party owe any taxes prior to the current year? Yes No

If YES to any of the above, please provide details

Does the borrower carry life insurance? Yes No

If yes, amount $

Full Name

Birth Date (MM/DD/YYYY)

Gender Male Female

Driver’s License

Current or most recent employer’s name

Employer’s telephone

Salary

Time employed here

Note: All information provided in this loan application will be strictly kept confidential between the Lender and the Borrower.

I accept the Terms and Conditons