You can either Print this document and fill out by pen, and then fax to: 502-267-1013 (click here for fax cover sheet) Or you can fill out the entire document except the signature lines and submit. Call Lori Sirkin at (502) 664-8244 if you have ANY questions.
I. Background
Date:
Business Name:		Phone	Fax
Business Address:
Own or Lease	Own:   Lease: (choose one)
Name of leasing agent		Phone
E.I.N.#
Current Business Type :
Date Established:
Type of company:	Corporation:    Partnership:    Sole Proprietorship
Business Principles	Name	Title	Soc. Sec. #
#1
Address:
Business Principles	Name	Title	Soc. Sec. #
#2
Address:
Business Principles	Name	Title	Soc. Sec. #
#3
Address:
Number of employees:
II. Credit
Trade References:	(Name and phone number of 3 suppliers of products regularly purchased)
Loan Information:	Lender	Phone#	Balance
	Address	Contact Name	Type of loan
Bank of Deposit	Account#
	By signing below I/we hereby certify that all information on this application is true and complete. I/we authorize you to investigate my/our credit record (both business and personal) and check the information I/we have prepared.
III. Compliance
	In conjunction with our application and as an inducement for you to approve this application, the undersigned hereby answers the following questions:
	#1. Is your company or any of its officers currently a defendant in any legal action?(Select) (yes or no)	Yes No
	#2.IF YES ABOVE: Is your company or any of its officers or stockholders (owners) presently under indictment or ever been convicted of a felony? (Select) (yes or no)	Yes No
	If yes, please explain:
	#3. Is your company or any of its officers or stockholders (owners) presently charged with or ever been convicted of any law relating to the business? (felony or misdemeanor)	Yes No
	If yes, please explain:
	#4. Is your company under investigation or has it in the last five years been investigated by any federal, state, or local government body for possible violation of law in conduct with this or any other company?	Yes No
	If yes, please explain:
	#5. Has your contractors license been revoked or suspended within the last five years? (Select) (yes or no) If yes, please explain	Yes No
	If yes, please explain:
	#6. Has your company ever been charged with an unfair or deceptive practice by the U.S. Federal Trade Commission or is there presently any investigation of your business activities by that or any other agency? (Select) (yes or no) If yes, please explain:	Yes No
	If yes, please explain:
IV. Insurance
Insurance Company	Name	Agent
	Address	Phone
	Amount of liability coverage	Company
	Worker's compensation Carrier
V. Financial
	Do you utilize a Certified Public Accountant? (yes or no) Please list name and phone number of CPA:	Yes No
	If no, who prepares your financial statements / tax returns? (Name and Number)
	Name	Title	Date
	Signature
	Name	Title	Date
	Signature