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SALEM BUSINESS LOAN PROGRAMS APPLICATION BUSINESS PROFILE Borrower's Name: Tax Identification # Trade Name: Telephone ( ) Principal Business Address: Mailing Address: Street: Street: City: , MA Zip City: , MA Zip Business Structure: C Corporation Partnership S Corporation Sole Proprietorship Trust Other: Unincorporated Association Nature of Business: Number of Employees: Year Established: MANAGEMENT / GUARANTORS NAME TITLE % OWNERSHIP SOC. SEC. NUMBER LOAN REQUEST TYPE: AMOUNT TERM (Years) BUSINESS PURPOSE Mortgage Term Comments: COLLATERAL If your collateral consists of real estate, accounts receivable and/or inventory, fill in the appropriate spaces. If you are pledging machinery and equipment, furniture and fixtures and/ or other, please provide an itemized list that contains all articles that had an original value greater than $1,000. Include a copy of last year's property tax bill and legal description of any real estate offered as collateral. ASSET DATE ACQUIRED ORIGINAL VALUE PRESENT VALUE PRESENT LOAN BALANCE COMMERCIAL REAL ESTATE PERSONAL REAL ESTATE MACHINERY & EQUIPMENT FURNITURE & FIXTURES ACCOUNTS RECEIVABLE INVENTORY OTHER TOTAL NOTES PAYABLE BANK NAME LOAN TYPE MATURITY DATE COLLATERAL PRESENT BALANCE PAYMENT ---PAGE BREAK--- BUSINESS FINANCIAL SUMMARY What is your primary bank of account? Deposit account number(s): Number of years experience in the industry by major owner(s): Have you or your business guaranteed any debts not listed on the financial statements? Yes No (If yes, what is total liability?) $ Is your business a party to any claim or lawsuit? Yes No Have you ever owned or operated a business which declared bankruptcy? Yes No Does your business owe any taxes for years prior to the current year? Yes No State whether more than 20% of sales are to one customer. Yes No (If you have answered yes to any of these questions, please provide the details as an addendum.) The applicant(s) hereby certify that the information contained in this application is provided to induce the Salem Department of Planning and Community Development (DPCD) to extend credit to the business. The applicant(s) acknowledge and understand that the DPCD is relying on the information provided in this application in deciding whether to grant credit. Each of you represents, warrant, and certify that the information is true, correct, and complete. Each of you agree to notify the DPCD immediately of any materially adverse change in any of the information contained in this application, or your or any proposed guarantor's financial condition. The DPCD is authorized to make all inquiries it deems necessary to verify the accuracy of the information contained in this application. You authorize any person or credit reporting agency to give the DPCD any information it may have about you. Each of you authorizes the DPCD to answer questions about the DPCD’s credit experience with you. You understand that the DPCD may request additional information to complete this application. CORPORATION, PARTNERSHIP OR TRUST APPLICANT: INDIVIDUAL OR SOLE PROPRIETOR APPLICANT(S): Name of Entity Signature Authorized Signature Print Name Print Name Signature Title Date Print Name Authorized Signature Print Name Title Date 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 Credit Protection Act.