Business Loan Application

BUSINESS LOAN APPLICATION

APPLICANT INFORMATION

Employee Information

Loan Request

Collateral Information

Credit Information

Please list all principals of the business:

BUSINESS LOAN APPLICATION
Business Name
Phone Number
Please enter a valid phone number.
Applicant's Name*
Home Phone*
Please enter a valid phone number.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Please list all principals of the business:
Name
Position
Name
Position
Name
Position
Please complete and submit a personal financial statements from each of the principals including applicant.*Please note additional supporting documentation specific to the loan will be required.

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APPLICANT INFORMATION
Full legal name of company/borrower
DBA if applicable
EIN/TIN/SSN
Phone Number
Please enter a valid phone number.
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nature of business
DUNs Number
Form of business

ProprietorshipPartnershipS CorporationC CorporationLLC
Number of years in business

Employee Information
Number of business owners employed by the business:
Current number of other full time employees:
Current number of part time employees
Will any jobs be CREATED as a result of the loan?

YESNO

If yes, how many do you project?

Rows	Title of job or work function	Full Time	Part Time	Number of positions	Projected hourly wage
1.
2.
3.
4.

Will any jobs (including owners) be SAVED as a result of the loan?

YESNO

If yes, how many do you project?

Rows	Title of job or work function	Full Time	Part Time	Number of positions	Projected hourly wage
1.
2.
3.
4.

Loan Request
Purpose of funds being sought:
PLEASE BE SPECIFIC

Please list items or use of funds:

Rows	Items or use of funds	Amount	This is an Estimate	This is a quote
1.
2.
3.
4.

Total Amount Requested
Have you been declined by a bank?

YESNO
If Yes, which bank
BANK NAME
Reason for decline
TYPE REASON
Please note: An application fee of 1% of the total amount requested will be charged for all approved loans. A document processing fee of 1% of the total loan amount will be also charged for all approved loans. Other charges may apply, such as a $25 charge for a credit report, $25 for filling each UCC, $25 for an amendment to a vehicle title and $205 to file a mortgage. These costs can be paid at closing or rolled into the loan itself. Please talk to your loan program coordinator for more information.

Collateral Information
Accounts Receivable:
VALUE
Are You Insured?

YESNO
Date

MonthDayYear
ATTACH AGING REPORT
TOTAL CURRENT OF INVENTORY
ATTACH ITEMIZATION

Equipment

Rows	Item	Current Value	Existing Lien Holder
Equipment
Equipment
Equipment

Inventory - total current value
ATTACH ITEMIZATION
Attach Files Here

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Real Estate

Rows	Type	Location	Market Value	Location
Real Estate
Real Estate
Real Estate

Savings Accounts/CDs:

Rows	Bank	Value	Type of Account
1.
2.
3.
4.

Vehicle(s)

Rows	Yr/Make/Model	Current Value	Existing Lien Holder
Vehicle
Vehicle
Vehicle

Other: describe Value: $

Credit Information
Do you have any outstanding unpaid sales, payroll, or income taxes?   YES   NO
Has you, your spouse, or your business ever declared bankruptcy?   YES   NO
Is this business a party or claim to any lawsuit?   YES   NO
If you answered YES to any of the first three questions, please explain in detail.

Please list all leases, mortgages, auto loans, charge accounts or other liabilities of the business:

Certification by owners or principals: The undersigned is providing this information to support its financing request and understands that QVBAC is relying on this information to support the financing request, and hereby represents that this information is true, correct and complete. The undersigned will provide notice of any change in his/her financial condition including his/her ability to perform under his/her obligations to the QVBAC. The undersigned authorizes any person or consumer-reporting agency to give QVBAC information it may have on the undersigned. The undersigned authorizes QVBAC to answer questions and/or provide credit information to credit reporting agencies and other parties.
Authorized Signature of Business Owner*

Clear
Date*

MonthDayYear
Printed Name/Title
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, religion, sex, gender identity, (including gender expression), sexual orientation, disability, age, marital status, family/parental status, political beliefs, or reprisal or retaliation for prior civil rights activity. Persons who require alternative means of communication for program information should contact us.

To file a complaint of discrimination, complete Complaint Form AD-3027, http://www.ascr.usda.gov/complaint_filing_cust.html or write USDA, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (866)632-9992 for a copy of the complaint form and fax to (202) 690-7442.
Please verify that you are human*
Should be Empty:

Loan Number

Original Amount

Current Balance

Monthly payment