MICROLOAN DISCOVERY INTAKE FORM
Rural Micro Entrepreneur Assistance Program (RMAP)
The following Counties/Cities are approved Rural areas for Florida & Georgia that are eligible for this program. Please select from the drop down list the area where your business resides in.
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FL-Putnam
FL-St. Johns/St. Augustine
FL-St. Johns/Hastings
FL-Madison/Madison
FL-Clay/Middleburg
FL-Clay/Orange Park
FL-Clay/Keystone Heights
FL-Clay/Green Cove Springs
FL-Madison/Greenville
FL-Hamilton/Jasper
FL-Jefferson/Monticello
FL-Gadsden/Quincy
FL-Monroe/Florida City
FL-Duval-Baldwin
FL-Okeechobee
FL-Hendry
FL-Baker
FL-Bradford
FL-Calhoun
FL-Columbia
FL-Desota
FL-Dixie
FL-Gilchrist
FL-Glades
FL-Gulf
FL-Holmes
FL-Levy
FL-Liberty
FL-Suwannee
FL-Taylor
FL-Union
FL-Wakulla
FL-Washington
GA-Glynn/Brunswick
GA-Laurens
GA-Camden
GA-Thomas/Thomasville
GA-Ware/ Waycross
GA-Crisp/Cordele
GA-McIntosh
GA-Terrell
GA-Lee
GA-Calhoun
GA-Tift
GA-Worth
GA-Colquitt/Moultrie
OTHER - Answer below
If you believe your business is located in a Rural area and not on the list above, Please enter the county and zip code and we will follow up with your request.
County / Zip Code
Borrower Name
*
First Name
Middle Name
Last Name
Borrower Home or Mailing Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is there a Co-Borrower?
Yes
No
Co-Borrower First Name
First Name
Last Name
Co-Borrower Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary Email
*
example@example.com
Borrower Mobile / Home Phone
-
Area Code
Phone Number
Borrower Fax Number
-
Area Code
Phone Number
Website
Borrower Mobile / Home Phone
*
Area code - Number
Borrower Fax Phone
Area code - Number
Business Name
*
Business Type
*
Business Location
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Business Phone
*
Area code - Number
Business Phone
-
Area Code
Phone Number
How long in Business
*
less than 1 year (START UP)
1-3 years
4-6 years
7-10 years
10 years or greater
How much money do you want to borrow?
*
$500-$999
$1000-$2499
$2500-$4999
$5k-$10k
$10k-$20k
$20k-$30k
$30k-$40k
$40k-$50k
How much money have you put into the business in the last three months?
*
How much money do you have to put towards your business along with the loan?
*
What will you do with the loan proceeds?
*
If known, what is your credit score?
*
What will you use as collateral?
*
Who do you bank with?
*
Do you have an existing RMAP Loan with another agency?
Yes
No
From time to time, Wealth Watchers collects follow-up information from its clients to learn more about the economic, business and employment experiences clients have experienced. I agree, as an active client, to provide certain information to Wealth Watchers on a timely basis. If I am asked to provide confidential data, I am assured that my name will not be attached to the data and I can be confident that the information will be shared in a trustworthy manner.
*
I accept
I do not accept
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