Website Questionnaire Form

Funding Pre-Qualification Questionnaire
Name*

First NameLast Name
Referred by*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Birthdate*

MonthDayYear
Date
Amount of Funding Needed ($10,000-$400,000)*
Funding Purpose*
1. Are you a U.S Citizen?*

YesNo
2. Do you reside in Iowa or California?*

YesNo
3. Do you have a Credit Score of 660 or higher on all 3 credit bureaus?*

YesNo
4. Do you have at least 3 open tradelines reporting on your credit report?*

YesNo
5. Is Your Income $27,000 or more Annually?*

YesNo
6. Do you have less than 6 inquiries in the last 6 months?*

YesNo
7. Do you have new credit lines open in the last 6 months (credit cards, credit card limit increases, car loan, mortgage, personal loan etc?)*

YesNo
8. Have you ever flied for bankruptcy?*

YesNo
9. If you have filed bankruptcy, is it at least 2 yrs. discharged?*

YesNoN/A
10. Are you employed or self-employed?*

EmployedSelf-EmployedBoth
11.If employed, have you been employed in your current position a minimum of 6 months, with at least 1 yr of continuous employment?*

YesNoN/A
12.If self-employed, have you been in business and filed taxes for the last 2 years?*

YesNoN/A
13.If self-employed, do you have a gross business income of at least $50,000 and a minimum net business income of $27,000 on your most recent 2 years of tax filings?*

YesNoN/A
14.If self-employed, do you pay yourself a salary?*

YesNoN/A
15.If self-employed, what is your business structure?*

LLCC-CorpS-Corp1099 (Independent Contractor)
16. Do you have any late payments, collections, judgements or anything that is derogatory reporting that is reporting in the last 2 years?*

YesNo
17. Do you have any medical bills reporting?*

YesNo
18. Do you have at least 50% left on your current credit card balances?*

YesNo
By submitting this form, you agree that the information provided is correct to your knowledge. The information provided in this form will not be shared and is kept confidential.
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Funding Pre-Qualification Questionnaire

By submitting this form, you agree that the information provided is correct to your knowledge. The information provided in this form will not be shared and is kept confidential.