Principal:

S.I.N.:

Birth Date:

Address:

City:

Postal Code:

Home Phone:

Fax:

Cell:

Email address:

Accountant:

Address:

Bus. Phone:

Bus. Fax:

Lawyer:

Address:

Bus. Phone:

Bus. Fax:

Name:

Address:

Tel:

Fax:

Account Nos: 1.:

2:

Account Manager:

Name: $:

S.I.N:

Address:

City:

Postal Code:

Birth Date:

Business Phone:

Home Phone:

Amount: $

Closing Date:

Term: 1 year2 year

Other:

Purpose:

Location:

Lot: Size: ft.

x: ft.

Building: Total Area: sq. ft.

Number of Floors:

Main Floor Area: sq. ft.

Further description:

Appraisal Completed? NOYES

Date of Appraisal:

Estimated Value:

Appraisal Completed? SurveyRent RollStatement of Income and ExpensesCurrent Financial StatementPrevious Year Financial Statement

Other Enclosures (list):

a)

Has an Engineering Report been prepared?

YesNo

b)

Has an Environmental Phase I Report been prepared?

YesNo

c)

Have you during the past five (5) years had any reportable releases or spills of hazardous substances, hazardous waste or any other pollutants, as
defined by applicable environmental statutes or regulations?
NoYes Provide Details:

d)

Have you during the last five (5) years been prosecuted, or are you currently being prosecuted, for contravention of any standard or law related to
the release or threatened release from the location of a hazardous substance, hazardous waster or any other pollutant?
NoYes Provide Details:

e)

At the time of the signing of this application, do you know of any facts or circumstances which may reasonably be expected to result in a claim or claims being asserted against you for environmental cleanup or response, or for bodily injury or property damage arising from the release of pollutants into the environment?
NoYes Provide Details:

Have any of the principals declared bankruptcy in the past 7 years?NoYes Provide Details:

Detail any prior or pending litigation:

I/We solemnly declare that all the aforementioned information is true and correct in every particular and is given for the purpose of obtaining the loan applied for intending the company to rely on the truth of my/our statement. I/We hereby authorize you, or anyone you appoint, to inspect my/our property and make any other inquiries or confirmations as deemed necessary by you to ascertain the feasibility of this application. I/We hereby agree to pay any and all valuation, legal and other expenses that you may incur in consequence of processing the loan application on my/our behalf. I/we agree that you may retain any placement fee payable by a lender.

I/WE HEREBY CONSENT TO ALLOW YOU TO CONDUCT OR CAUSE TO BE CONDUCTED A PERSONAL INVESTIGATION OF THE APPLICANT, PRINCIPAL OF A CORPORATE APPLICANT, AND ANY GUARANTOR AND TO DISCLOSE THE INFORMATION TO OTHER CREDIT GRANTORS AS REQUIRED.

Dated At:

, This

Day Of:

20:

Applicant:

Title:

I Have Authority To Bind The Corporate Applicant

 

Witness:

Print Witness Name: