Fill Out Our Bank Business Loan Applications For Business Loans

Business Information

* Indicates a Required Field
Are you working with a Middlefield Bank employee on this loan? Yes No
Employee Name
Form of Entity:
Line of Business:
Number of Employees:
Business Primary Phone:
Primary Deposit Relationship Institution:
Business Tax ID#/SSN:
Gross Annual Revenue:
Business Website:
Business Email Address:
State & County of Organization:
Date of Incorporation:

Primary Contact

Name:
Title:
Phone Number:
Email Address:

Business Attorney

Name:
Email:
Phone Number:

Business Accountant

Name:
Email:
Phone Number:

Insurance Agent

Name:
Email:
Phone Number:

Loan Request Information

Amount of Credit Requested:
Purpose of Loan:
Collateral Offered:
Owner of Collateral:

Ownership Information

Name:
SSN:
Phone#:
Cell Phone#:
Address:
City:
State:
Zip Code:
Title:
% of Ownership:
Driver's License Number:
Date Issuance:
Date of Birth:
Annual Compensation:

Notices to Applicant

Right to Receive a Copy of Appraisal: If your loan will be secured by a lien on a 1-4 unit residential dwelling, we may order an appraisal to determine the property's value and charge you for this appraisal. We will promptly give you a copy of any appraisal, even if your loan does not close. You can pay for an additional appraisal for your own use at your own cost.

ECOA Notice: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract; because all or part of the applicant's income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Protection Act. The Federal agency that administers compliance with this law concerning this creditor is: The Federal Deposit Insurance Corporation, Consumer Response Center, 1100 Walnut Street, #11, Kansas City, MO 64106

If you are denied credit, you have the right to a statement of specific reasons within 30 days, if the statement is requested within 60 days of denial. You may request a written statement by contacting Park Bank at P.O. Box 8969, Madison, WI 53708, Telephone 608-278-2801..
Certification and Authorization

The information contained in this request for credit is provided for the purpose of obtaining credit with Park Bank on behalf of the Borrower(s). By submitting this Request the Borrower(s)
1. Warrants and represents that the information provided is true and correct and understands that Park Bank will rely upon this information to make a credit decision.
2. Authorizes Park Bank to verify the accuracy of the information contained in this application or in conjunction with this application through additional sources as deemed necessary.
3. Acknowledges that it may be a federal crime to knowingly make false statements concerning any of the above information under Title 18, United States Code Section 1014.
4. Agrees to pay all third party costs without limitation that are incurred by Park Bank throughout this process. Third party costs include, but are not limited to, appraisals, credit report, flood determination, environmental, title work, etc.). Borrower(s) agrees to pay all third party feel regardless of whether the loan closes.
Yes, I accept the Certifications and Authorizations

Do you accept credit cards as a form of payment? Yes No
Do you have a need for ACH? Yes No
Do you use corporate credit cards? Yes No
Do you currently have a 401K plan? Yes No

Business Loan Application

Move Your Business Forward

Business Information

Primary Contact

Business Attorney

Business Accountant

Insurance Agent

Loan Request Information

Ownership Information

Notices to Applicant

Certification and Authorization