Loan/Forgivable Loan Intake Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Business/Organization Name
*
Business Type
*
Please Select
Nonprofit
For-profit
Startup
Other
Business Structure
*
Please Select
LLC
Sole Proprietor
Partnership
Corporation
Contact Person Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
EIN/TAX ID
*
Industry Type
*
Years in Operation
*
Number of Employees
*
Annual Revenue Range
*
Please Select
$0-$50k
$50k-$100k
$100k-$$500k
$500k+
Funding Need
*
Please Select
Grant
Forgivable Loan
Government Contract
All
Funding Purpose
*
Brief Description: Growth, Equipment, Payroll, Program, etc.
Prior Funding History
*
Yes/No - if yes, which programs?
Geographic Focus
*
National, State, Local
Credit Readiness
*
Please Select
Good
Fair
Poor
Financial Docs Available
Tax Returns
P&L
Balance Sheet
Cash Flow
Bank Statements
Financial Docs
*
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of
Funding Amount Requested
*
$60,000.00
Funding Use Case
*
Please Select
Working Capital
Payroll
Expansion
Equipment
Marketing
Previous Loan Experience
*
Yes/No - details if yes
How Did You Hear About Us
*
Please Select
Referral
Website
Billboard
Google
Affiliate
Family/Friend
Other
Other
*
If Other Please Elaborate
File Upload
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Choose a file
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of
Signature
*
Date
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
Continue
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