looking to get a custom form created as outlined below. info should be saved into a mysql database. would like an admin panel to download information via csv/txt file. we will provide PSDs for site template…please ask any questions you may have….
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Create Account
User Name: [Open Field]
Password: [Open Field]
Confirm Password: [Open Field]
How did you hear about us? [Drop Down]
Have you ever had a loan with us [Check Box] Yes [Check Box] No
By creating an ID and password you will be able to retrieve your incomplete/un-submitted online
application for up to 30 days. After 30 days you will need to start a new online application. Applications
are not reviewed until the Submit button is clicked at the end of the application.
Loan Request
Primary Purpose of Loan: [Drop Down]
Amount Requested: [Open Field]
Business Information
Legal Name of Business: [Open Field]
Address: [Open Field]
City: [Open Field]
State: [Open Field]
Zip: [Open Field]
Phone: [Open Field]
Email Address: [Open Field]
Website (if available): [Open Field]
Type of Business Entity: [Drop Down]
Tax ID Number: [Open Field]
Description of Business: [Open Field]
Date Business Established: [Open Field]
Years in Business: [Open Field]
Number of Employees: [Open Field]
Business Bank Name: [Open Field]
Checking Balance: [Open Field]
Gross Sales/Revenue Last Year: [Open Field]
If Start Up: Revenue Assumptions: [Open Field]
Business Debt
Include all term loans, credit lines, credit cards
Creditor #1
Bank or Lending Institution: [Open Field]
Contact Name: [Open Field]
Contact Phone: [Open Field]
Contact Email: [Open Field]
Total Credit Extended: [Open Field]
Monthly Payment Amount: [Open Field]
Balance Due: [Open Field]
Creditor #2
Bank or Lending Institution: [Open Field]
Contact Name: [Open Field]
Contact Phone: [Open Field]
Contact Email: [Open Field]
Total Credit Extended: [Open Field]
Monthly Payment Amount: [Open Field]
Balance Due: [Open Field]
Creditor #3
Bank or Lending Institution: [Open Field]
Contact Name: [Open Field]
Contact Phone: [Open Field]
Contact Email: [Open Field]
Total Credit Extended: [Open Field]
Monthly Payment Amount: [Open Field]
Balance Due: [Open Field]
Personal Information
Please provide information on all guarantors. Information must be provided on all owners who owner
20% or more of the business
Guarantor #1
First Name: [Open Field]
Last Name: [Open Field]
Social Security Number: [Open Field]
Percentage of Ownership: [Open Field]
Bank Name: [Open Field]
Monthly Mortgage or Rent Payments: [Open Field]
Total Other Monthly Payments: [Open Field]
Annual Salary: [Open Field]
Annual Salary from This Business (If Applicable): [Open Field]
Other Household Income: [Open Field]
Total Income: [Open Field]
Guarantor #2
First Name: [Open Field]
Last Name: [Open Field]
Social Security Number: [Open Field]
Percentage of Ownership: [Open Field]
Bank Name: [Open Field]
Monthly Mortgage or Rent Payments: [Open Field]
Total Other Monthly Payments: [Open Field]
Annual Salary: [Open Field]
Annual Salary from This Business (If Applicable): [Open Field]
Other Household Income: [Open Field]
Total Income: [Open Field]
Guarantor #3
First Name: [Open Field]
Last Name: [Open Field]
Social Security Number: [Open Field]
Percentage of Ownership: [Open Field]
Bank Name: [Open Field]
Monthly Mortgage or Rent Payments: [Open Field]
Total Other Monthly Payments: [Open Field]
Annual Salary: [Open Field]
Annual Salary from This Business (If Applicable): [Open Field]
Other Household Income: [Open Field]
Total Income: [Open Field]
Terms & Conditions
[Term & Conditions Copy]
I have read, understand and agree to adhere to the stated Terms & Conditions: [Check Box]
Save & Finish Later [Button]
Submit & Complete Now [Button]
