Commercial Loan Inquiry Business Information Borrower Legal Name Business TypeSole ProprietorCorporationPartnershipLLCNon-ProfitOther Business Type Street Address City StateSelect StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Mailing address is different than street address. Mailing Address City StateSelect StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Designated Company Contact (DCC) Information First Name Last Name Business Phone Number E-mail Address Please do NOT email me important news and updates. Business Details Date of Establishment IndustryAgriculturalRetailBusinessWholesaleManufacturingProfessional ServicesOther Industry Description Credit Request Credit Credit TypeSelect Credit TypeLine of CreditLoanLeaseReal EstateOther Amount Collateral Use of Funds -+ Endorsement I certify that all information provided by me herein, including attachments (s) is true, correct and complete. I authorize Mound City Bank to make whatever inquiries about me you deem necessary and appropriate for the purpose of evaluating my credit, including obtaining credit reports and contacting my employer. I also authorize Mound City Bank to provide credit information about its credit experience with me to other creditors and credit reporting agencies. I authorize the Bank to obtain address information from the Department of Motor Vehicles and waive the address confidentiality requirements of the State Vehicle Code. I agree to provide any further information the Bank might require to process my application. Applicant's Signature Date Submit
