Montgomery County Revolving Loan Fund
Participation Agreement Application
Date of Application:
Revised Date of Application:
Applicant of Funds:
Contact Person:
Street Address:
Mailing Address:
City, State, Zip:
Sponsoring Financial Institution:
Contact Person:
Street Address:
Mailing Address:
City, State, Zip:
Phone:
Fax:
Email:
Phone:
Fax:
Email:
Preferred Method of Contact:
Preferred Method of Contact:
Dollar Amount Requesting for
Participation:
Please provide one or two sentence describing uses of funds:
Total Dollar Amount of Funds
Needed for Project:
List Sources of Funding and Amount Each is Funding (Round to Nearest Whole Dollar):
Source
Dollar Amount
Anticipated Date Funds Needed:
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Repayment Schedule (attach separate
sheet if needed):
Term of Loan:
Collateral for Total Project (Round to Nearest Whole Dollar):
List of Collateral
Source and Date of Valuation of
Collateral
Dollar Value for Each Item
Position Montgomery County Revolving
Loan Fund Will Have on Collateral
If more space is needed to list collateral, please attached separate sheet.
Number of Jobs Business
Currently Has as of Date of
Application in Montgomery
County:
Full Time:
Part Time:
Number of Jobs Business will
be able to Retain in Montgomery
County if Participation
Agreement takes place:
Full Time:
Part Time:
Number of Jobs Business will
be able to Create in
Montgomery County if
Participation Agreement takes
place:
Full Time:
Part Time:
Disclaimer 1: By completing and signing this application you give the Montgomery County Revolving Loan Fund Board the right to confirm that all
information provided is accurate and the right to check the credit history of the applicant. Completion of this form does not guarantee that a participation
agreement will be entered into between the Montgomery County Revolving Loan Fund and the sponsoring Financial Institution for the applicant. If a
participation agreement is entered into, on an annual basis the applicant end user of the funds will be required to report employment statics to the
Montgomery County Revolving Loan Fund Board.
Disclaimer 2: Applicant's information may need to be revealed due to a valid Freedom of Information Act request.
Signature of Applicant(s):
Signature of Contact Person
from Sponsoring Financial
Institution:
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