Business Express Loan Payment Program

Business Information

Business/Borrower's Name

Address Line 1

Address Line 2

City

State

ZIP

Mailing Address If Different

Email Address

Phone Number

Entity Type (Inc/Partnership/LLC/Sole Prop)

DBA

Company Website

EIN #

Time in business (years)

Loan(s) Amount Requested

Current ownership since

Annual Revenues

Guarantors (All owners with greater than 25% ownership)

Name/Title

Ownership %

SSN

DOB

Phone #

Address Line 1

Address Line 2

City

State

ZIP

Guarantors Signature

Date

Name/Title

Ownership %

SSN

DOB

Phone #

Address Line 1

Address Line 2

City

State

ZIP

Guarantors Signature

Date

Are there any law suits, judgments or tax liens against the Applicant or any of the above principals, or has the Applicant or any of the above principals ever declared bankruptcy? Yes No

If yes to any of the above, please explain

Equipment being purchased / Refinanced / (repeat for each loan as needed)

Type of Equipment

Vin # / Serial #

Purchase Price

New or Used New Used

Vendor

Contact

Address Line 1

Address Line 2

City

State

ZIP

Type of Equipment

Vin # / Serial #

Purchase Price

New or Used New Used

Vendor

Contact

Address Line 1

Address Line 2

City

State

ZIP

This is a secure form. Addresses will be changed based on accounts with corresponding SSN or Tax ID. Please allow 2-3 business days for completion of your request. The undersigned certify(ies) that the pages herein and any schedules attached hereto (the “Information”) have been carefully read by the undersigned, and the Information included is true and correct. The undersigned give(s) the Information for the purposes of obtaining credit and authorize(s) First Federal to investigate his or her credit through any credit bureau or by any other reasonable means, including contracting creditors listed on these pages. I/we acknowledge that all loan commitments must be in writing, and nothing that has been, or may be, stated orally shall be construed as a commitment.

Applicant's Signature

Title

Date