Full Name:

Company:

Address:

City:

State:

Zipcode:

Home Phone:

Mobile Phone:

Fax Number:

Email:

County Resident:

Choose One Yes No

Referral Source:

Industry:

Type of Business:

Choose One LLC Sole Corp.

# of Employees:

Choose One 1-5 6-10 11-20 >20

Annual Sales:

Choose One < $100,000 $100,000 - $250000 $250000 - $500000 > $500000

Years of Operating History:

Choose One < 1 2 - 4 5 - 7 > 7

Experience in the Industry:

Choose One Yes No

Type of Business:

Choose One Expansion Retention Start-Up Franchise

Loan Type:

Choose One 7(A) 504

Total Project Cost:

Loan Amount:

What will the loan proceeds be used for?

How much equity have you invested in the business?

Choose One < $100,000 $100,000 - $250,000 $250,000 - $500,000 > $500,000

Type of Equity:

Choose One Cash Equipment Property

Do you have a Business Plan?

Choose One Yes No