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Please complete the following information and a representative will contact you as soon as possible regarding your application.

The information collected from this form will only be used by First Bank and its affiliates.

Contact Information:

Name
Business Name
Address
Address (cont'd)
City, State Zip	,
Phone
FAX
E-mail

How would you prefer to be contacted?

Please give a brief description of your business:

What is the loan amount you are requesting?
$ .00

How many years have you been in business?

Please give a brief description of how the loan proceeds will be utilized?

If the use of funds listed above does not include the purchase of real estate, do you own any real estate that you are willing to pledge as collateral for the project:

Declarations
Please answer the following questions as they may apply to the applicant company, each officer, each director and each owner of 20% or more of the applicant company. For each "yes" we will require a complete signed exhibit providing a detailed explanation from the source.
Yes No	1. Are any involved in any claim or lawsuit?
Yes No	2. Are any federal, state, or local taxes delinquent?
Yes No	3. Have any ever been involved in bankruptcy or insolvency proceedings?
Yes No	4. Do any have outstanding judgments?
Yes No	5. Have any ever had property foreclosed upon or given title or deed in lieu of foreclosure?
Yes No	6. Are any NOT citizens of the United States?

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