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?

YesNo
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?

YesNo
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 acceptI do not accept
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