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Mortgage Resource Center - Apply Online 27/4
 

Business Loan Application

Fill out the form below, sign by typing your full name, and click "Submit."

If you have any questions, please contact us.

All information marked with an * is required

Applicant Information
Borrower: *
Tax I.D. Number: *
Business Address: *
City: *
County: *
State: *
Zip: *
Contact Name: *
Title: *
Phone: *
Business Phone: *
Business Fax: *
Year Established: *
Current Owners Since: *
Annual Sales: *
Number of Locations: *
Form of Business
Organization: *




Number of Employees: *
Type of Product or Service: *
Where do you presently bank? *
What is your average
checking account balance? *
Loan Request
Amount Requested: * $
Purpose of Loan - Description: *
Description of Collateral Offered: *
Principal Officers (20% or more ownership) & Guarantors:
1. Name: *
Guarantor
Title: *
Date of Birth: *
(MM/DD/YYYY)
Address: *
City: *
State: *
Zip: *
Phone: *
Drivers License: *
E-mail Address: *
SSN: *
Ownership: * ‰
Spouse: *
SSN: *
2. Name:
Guarantor
Title:
Date of Birth:
(MM/DD/YYYY)
Address:
City:
State:
Zip:
Phone:
Drivers License:
E-mail Address:
SSN:
Ownership: ‰
Spouse:
SSN:
3. Name:
Guarantor
Title:
Date of Birth:
(MM/DD/YYYY)
Address:
City:
State:
Zip:
Phone:
Drivers License:
E-mail Address:
SSN:
Ownership: ‰
Spouse:
SSN:
Financial Information and Supporting Documentation:

The following additional information may be requested after review of the loan application.

  • Borrower's year end financial statements and/or tax returns (past 3 years)
  • Borrower's interim financial statements (within 60 days)
  • Detailed schedule of all indebtedness
  • Personal financial statements of principals (with greater than 20‰ ownership) or guarantors or co-signers
Certifications *
Is the business entity or its principals/guarantors, an endorser or co-maker for obligations not listed on the financial statements? *

If Yes, please provide explanation.
Has the business entity, or its principals/guarantors ever been involved in any bankruptcy proceedings? *

If Yes, please provide explanation.
Is the business entity, or its principals/guarantors involved in any pending lawsuits or have any outstanding judgments against them? *

If Yes, please provide explanation.
Disclosures
I (we) certify that the information provided in this application and supporting documents is true and correct and authorize Coulee Bank to verify and obtain additional information concerning our credit. I/we understand that it may be a federal crime to make false statements, punishable by a fine or imprisonment or both, under Title 18 of the United States Code Section 1014.
All Principals are Required to Sign this Credit Application *
Signature:
E-mail:
Title:     Date:
Signature:
E-mail:
Title:     Date:
Signature:
E-mail:
Title:     Date:
Verification code:
If the words/letters in the verification box are difficult for you to read, click the refresh button in the verification window (the first button to the right of the yellow box). If you do type in the verification code wrong and come back to this page, all of your information will be gone, you will then have to re-enter all of your information. This is done for your security.



On October 3, 2008, FDIC deposit insurance temporarily increased from $100,000 to $250,000 per depositor through December 31, 2013. For more information please contact Coulee Bank or visit www.fdic.gov.

Beginning July 1, 2010 Coulee Bank will no longer participate in the FDIC’s Transaction Account Guarantee Program. Thus, after June 30, 2010, funds held in non-interest bearing transaction accounts will no longer be guaranteed in full under the Transaction Account Guarantee Program, but will be insured up to $250,000 under the FDIC’s general deposit insurance rules.
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