MICROLOAN DISCOVERY INTAKE FORM

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.
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 NameMiddle NameLast Name
Borrower Home or Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Is there a Co-Borrower?
Co-Borrower First Name

First NameLast Name
Co-Borrower Address

Street Address

Street Address Line 2

CityState

Zip Code
Primary Email
example@example.com
Borrower Mobile / Home Phone

Area CodePhone Number
Borrower Fax Number

Area CodePhone 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

CityState

Zip Code
Business Phone
Area code - Number
Business Phone

Area CodePhone Number
How long in Business
How much money do you want to borrow?
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?
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.
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