Welcome to Citizens National Bank
Business Loan Application
Please choose types of loan you are applying for (check as many as apply)

Commercial Line of Credit  Term Financing
Commercial Revolving Account Real Estate Loan
Equipment Financing    

1. General Information
Please fill out the following:

Borrower Name    Tax ID# 

Address            

Contact Name             

Contact Phone #  Contact Fax #

Contact Email Address  

Contact Title    

2. Ownership/Management Structure
Please choose one form of Mangagement Structure:

  Corporation                              General Partnership           Individual/Proprietorship

  Sub-Chapter S Corporation       Limited Partnership            Limited Liability Company

  Professional Corporation           TBA or DBA                       Other

Please declare percentages and names of companies owned  

Name of Company Percentage
   
   
   
   

Please list Key Management:

Name    Age 

Titles/Duties 

Years with Company       Life Insurance Amount 

Annual Salary         Annual Bonus 

Name    Age 

Titles/Duties 

Years with Company       Life Insurance Amount 

Annual Salary        Annual Bonus  

Name    Age 

Titles/Duties 

Years with Company       Life Insurance Amount 

Annual Salary        Annual Bonus  

Name     Age

Titles/Duties 

Years with Company      Life Insurance Amount 

Annual Salary       Annual Bonus  

Please list Subsidiaries or Affiliates (Owned by applicant or by management or owners of applicant):

Name of Subsidiary or Affiliate Percentage   Owned Owned by Whom Line of Business
       
       
       
       

3. Company History/Profile
    Date Company Founded     Founded By 

    City/State of Founding 

    State of Incorporation       Date Incorporated 

    Type of Business          

    Number of Full Time Employees  

     Number of Part Time Employees 

    Number of Employess Total         

Please enter information on your 4 largest Customers:

Customer Name 

Address             

Contact Name        Phone Number 

Annual Sales    

Customer Name 

Address             

Contact Name       Phone Number 

Annual Sales    

Customer Name 

Address             

Contact Name       Phone Number 

Annual Sales    

Customer  Name 

Address              

Contact Name         Phone Number 

Annual Sales     

Please enter information on your 4 largest suppliers:
Supplier Name 

Address           

Contact Name      Phone Number 

Annual Purchases 

Supplier Name 

Address           

Contact Name     Phone Number 

Annual Purchases 

Supplier Name 

Address           

Contact Name     Phone Number 

Annual Purchases 

Supplier Name 

Address            

Contact Name      Phone Number 

Annual Purchases 

4. Description of Proposed Financing
Amount Requested:      Date Needed:

Source of Loan Repayment:

Please check reason for Loan Request (check all that apply)

   Purchase of Inventory                                          Purchase/Refi of Real Estate

   Growth of Accounts Receivable                            Purchase of a Business

  Buy-Out of Partner/Shareholder                              Purchase of Equipment

  Other (Please specify)

Please check requested Term of Loan:

      Revolving                         9 Months                            3 Years (36 Months)

      3 Months                          1 Year (12 Months)            4 Years (48 Months)

      6 Months                          2 Years (24 Months)           5 Years (60 Months)

      Other (Please Specify)

Please Check Collateral Offered or Available (check all that apply):

Accounts Receivable Real Estate

Inventory Marketable Securities

Equipment Cash (My Acct #):

  Personal Assets (Please Specify)

  Other Assets (Please Specify)

Other Information 

If yes to any of the following questions, please explain.

Please answer the following questions for the business and the owner(s).
 Business
(yes)		 Person
(yes)
1. Are there any claims or lawsuits pending?
2. Are any State or Federal Income, Withholding, Sales or Property taxes delinquent?
3. Does any liability exist for any accounts via leases, guarantees, commitments or other contingency agreements?
4. Have there been any bankruptcies or judgements?
5. Is there any collateral offered to CNB currently pledged to other creditors?
6. Are any assets held in a Trust?
It is understood that this may not be a complete application and CNB may need additional information to properly evaluate the credit request.

5. Support Information
The Following Information may also be Required:
  • 2-3 Years of Financial Statements and Tax Returns for borrower(s)
  • Current Personal Financial Statements and 2 years of tax returns for all principals or guarantors.
  • Receivables Aging, Backlog, Contract Progress Reports (if applicable)
  • A list of subject inventory, and/or subject equipment with serial numbers (if applicable)
  • A list describing Marketable Securites and number of shares. (if applicable)
  • Sales Contract and/or Purchase Agreement (if applicable)
  • Financial projections and Business Plan (if applicable)

Name and Address of Landlord  

           Annual Rent  

      Lease Expiration                                        

Additonal Comments (if any)
By signing or submitting this application the applicant(s) specifically ackknowledge and agree that: (1) All statements made in this application are made for the purpose of obtaining the loans indicated herein; (2)Verification or reverification of any information contained in the application may be made at any time by the lender, its agents, successors, and assigns, either directly of through a credit reporting agency, from any source named in this application; (3)The original copy of this application will be retained by the lender, even if the loan is not approved;(4)The Lender, its agents, successors and assigns will rely on the information contained in the application and I/we have a continuing obligation to amend and/or suppliment the information provided in this application if any of the material facts which I/we have represented herein should change prior to closing; (5) In the event my/our payments on the loan indicated in this application become delinquent, the lender, it's agents, successors and assigns, may, in addition to all other rights and remedies, report me/our name(s) and account information to a credit reporting agency; (6) ownership of the loan may be transferred to a successor or assign of the Lender without notice to me and/or the administration of the loan account may be transferred to an agent, successor or assign of the Lender with prior notice to me; and (7) that all expenses for legal fees, title examination, appraisal, and settlement or other chargees of the loan are to be paid by the borrower.

Certification: I/We certify that the information provided in this application is true and correct as of the date of submission on this application and acknowledge my/our understanding that any intentional or negligent misrepresentation(s) of the information contained in this application may result in civil liability and/or criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, et seq. and liability for monetary damages to the Lender, its agents, successors and assigns, insurers and any other person who may suffer any loss due to reliance upon any misrepresentation which I/we have made on this application.

Signature Date
Signature Date
Signature Date
 
By submitting this form, I accept that it is legally binding.