Credit Required For 30 Day Period: $
 
Applicant Firm:
Name:
Street:   
City:
State:        Zip:
Phone: ()
Fax: ()
Email:
Business Description
Date of Ownership / Control: (MM/YYYY)
Bank Name:
Bank City:
Bank State:
Bank Phone: ()
DUNN & BRADSTREET NO: (If Registered):
 
COMPLETE THIS SECTION IF APPLICANT IS A CORPORATION
Incorporated State:  
Is Applicant a Subsidiary? Yes No.    If Yes, Complete the Subsidiary Section
Has Business ever declared Bankruptcy? Yes No.    If Yes, Date filed
COMPLETE THIS SECTION IF APPLICANT IS A SUBSIDIARY
Parent Name
Date of Ownership (MM-YYYY)
Street
City
State    Zip
Phone ( )
Business Description: 
COMPLETE THIS SECTION IF APPICANT IS A PROPRIETORSHIP PARTNERSHIP, OR ASSOCIATION
Owner, General Partner, or Guarantor:
Percent Owned:   
Resident Address:
Street:
City:
State : Zip:
How Long at this Address (Yrs):  
Has Owner, General Partner, or Guarantor ever declared bankruptcy? Yes No
If Yes, Date Filed (MM/YYYY):
BALANCE SHEET (Rounded Actual $) 
Firm Name
ASSETS: Current Assets Current Period (MM/YYYY) Prior Period (MM/YYYY)
Cash
Accts. Receivable
Inventory
Other Cur Assets
Total Current Assets
Non-Current Assets
Land, Bldgs,Furniture,Fixtures
Equipment & Machinery
Other Assets
Total Non-Current Assets
 
Total Assets Current+Non-Current)
 
LIABILITIES
 Current Liabilities:
 Accounts Payable
 Accrued Liabilities
Long Term Debit (Due with in a year)
 Other Current Liabilities
Total Current Liabilities
Long Term Liabilities
Long Term Debit (Due after a year)
Deferred Taxes
Other Liabilities
Total Long Term Liabilities
 
Total Liabilities (Current + Long Term)
 
EQUITY
Common Stock
Additional Paid in Capital
Retained Earnings
Total Equity
 
Total Liability+Equity
Note: Total Liability and Equity must equal to total Assets
 
INCOME STATEMENT
Revenue/Sales
Less Depreciation
Less Other Operating Expenses
Operating Income
Plus Other Income
Less Other Expenses
Income Before IncomeTax
Less IncomeTax
Current
Deferred
Net Income
Note: Submitting this form confirms your acknowledgement that the information provided is correct to the best of your knowledge.