Credit Application Form

Credit Application

199Creative

Length of Financing Desired: *

12 months

18 months

24 months

Line of Credit Requested *

Business Name: *

Phone Number: *

Street Address: *

City, State, Zip *

How many years have you been in business? *

D/B/A *

Federal Tax ID Number: (EIN) *

Drivers License Number: *

State of Issuance: *

Upload image of valid driver's license

Ownership: *

LLC

Sole Ownership

Corporation

Partnership

Applicants Full Name: *

Applicant Title: *

Applicant Social Security Number *

Applicant's Home Address *

Applicant's Cell Phone Number: *

Co-Applicant Full Name:

Co-Applicant Social Security Number

Co-Applicant Title:

Bank Reference: *

Checking

Loan

Savings

Bank Name and Phone Number: *

Account Number: *

Annual Income: *

Have any of your officers, self, or this business ever filed for bankruptcy? *

*If yes, explain in detail:

The undersigned will/will not submit a financial statement. Any misrepresentation in this application will be considered evidence of fraud, since this information is the basis for granting of credit. As an inducement to grant credit, the undersigned warrants that the information submitted is true and correct. *

I acknowledge

Sign and Date: *

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