Business Funding Request Form
Contact Information
Full Name
*
First Name
Last Name
Business Name
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Business Information
Is the business currently operating?
*
Yes
No
How long has the business been in operation?
*
Please Select
Less than 6 months
6–12 months
1–2 years
2+ years
What type of business ownership structure applies?
*
Please Select
Sole proprietorship
LLC
Corporation
Partnership
Other
What industry is the business in?
*
Funding Request
Amount of Funding Requested
*
Under $25,000
$25,000–$50,000
$50,001–$100,000
$100,000+
Funds Will Be Used For
*
Startup costs
Equipment
Inventory
Marketing
Payroll
Working capital
Expansion
Commercial real estate
Other
Business Financials
Approximate annual business revenue
*
Startup / no revenue
Under $50,000
$50,000–$100,000
$100,001–$250,000
$250,000+
Business checking account
*
Yes
No
Business tax returns filed
*
Yes
No
Not applicable
How long has the EIN been held?
*
Less than 6 months
6–12 months
More than 1 year
I don’t have an EIN
Eligibility
Estimated Personal Credit Score
*
Below 580
580–619
620–679
680–719
720+
Ever Declined for Business Funding?
*
Yes
No
Ever Filed Bankruptcy?
*
Yes
No
Outstanding Tax Liens or Business Collections?
*
Yes
No
Funding Goals
When do you need the funding?
*
Immediately
Within 30 days
Within 60–90 days
Just exploring options
Anything else we should know about your funding needs?
Submit
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