Applicant Name:
Type of Applicant:Individual(s) Corporation Partnership Trust Other
Contact Name:
Spouses Name:
Address: City: State: Zip:
Daytime Phone #: Evening Phone #:
Mobile Phone #: Fax #:
Best time of day to contact:
E-mail:
Amount of Loan Request:$200,000 Minimum loan size
Describe general purpose (use of funds) for loan request (refinance Real Estate debt, refinance other debt, purchase Land, Cash out, etc.):
Describe agriculture property offered as collateral for requested loan:
Number of Acres: Estimated Value:
Location of collateral property, County and State:
Indicate the primary Agriculture Commodities produced on the land offered as security:
Please indicate which of the following best describes your credit history (do NOT order a credit report on yourself):
Excellent history, no derogatory, very limited delinquency, high score Good history, no derogatory, minor delinquency, good score Some adverse history or minor derogatory(s), few delinquencies, reasonable score Poor History, multiple derogatory(s), and/or multiple repeating delinquencies