Appendix B
OSAGE COUNTY E-COMMUNITY APPLICATION
Date: ______
Section 1: Personal Information
Name: ______
First MI Last
Street Address: ______
City: ______State:______Zip:______
County: ______Email: ______
Phone: ______Fax:______
Cell Phone:______Social Security #______
Section 2: Business Information
Business Name:______
Business Address ______
City:______State:______Zip:______
Business Telephone: ______Business Website:______
Are you applying as an:
- Sole Proprietorship: Provide a Financial sheet,
- Jointly: Provide financial sheets for both persons applying
- Partnership: Provide Financial sheet on all partners & Partnership agreement
- LLC: Provide Management agreement
- Corporation: Provide Corporation Resolution
Federal ID #______
Loan Application:
Section A: Planning:
Have you completed a business plan? Yes_____No_____If “yes” please attach a copy
Section B: Legal:
Any unresolved person/business judgments, unsettled lawsuits or major disputes?
Yes_____No_____
Has the business, or any principals of the business, been involved in bankruptcy or insolvency proceedings?
Yes_____No_____ If “yes” please give date and explanation:
______
______
Section C: Financing Information:
Date needed ______
Are the funds to be used for:
- Business startup
- Expansion of existing business
- Purchase of an existing business
- Retention of a current business
Purpose of Loan: Personal (not borrowed) funds available to
Invest in business
Working Capital = $______Cash = $______
Equipment = $______Assets = $______
Inventory = $______Total Funds to Invest = $______
Total Loan Request = $______
Additional funding that will be utilized in this project:
Bank Loan $______Investors $______
Equity injections $______
Please provide the following information:
- Projected sales
- Sales growth
- Cash flow
- 3 years of tax information
Section C: Certifications
Please read the following and sign the Application Form below. All owners, officers, partners, member and stockholders must sign this application. Potential co-signers and guarantors must also sign this form. Signing this application serves as each person’s express permission that Osage County E-Community may obtain the person’s credit report, as well as authorization and confirmation of the following statements.
By signing below, I authorize Osage County E-Community, and its assigned agents, to obtain a credit report on me through the credit reporting agency of its choice and to make such other investigations as deemed necessary. I understand that Osage County E-Community may verify, from all and any sources, all information provided. I understand that Osage County E-Community may call prior lenders and creditors to verify credit information, as well as answer questions others may ask about my credit record with Osage County E-Community. I authorize Osage County E-Community to keep this application whether or not my request for credit is approved.
The information in this application is provided for the purpose of applying for funds under the Osage County E-Community Load Program. The information is true and accurate to the best of my knowledge. I understand that personal and/or business information may be requested pursuant to this loan application, and I hereby give my consent for such information to be provided to Osage County E-Community. I also understand the Osage County E-Community retains the sole decision as to whether this loan application is approved, disapproved, or modified. It is my right to accept or decline the loan amount, the rate, and the terms approved by Osage County E-Community loan committee. Osage County E-Community does not discriminate against applicants on the basis of race, color, religion, national origin, sex, marital statue or age.
Name (printed) ______Signature:______Date______
Name (printed) ______Signature:______Date______
Name (printed______Signature:______Date______
Please return Application Fee to:
Osage County E-Community
P.O. Box 262
Lyndon, KS 66451
785-828-3242
Please attach any additional information you feel might help the loan committee.