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Home
» Intake Form
Intake Form
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Date
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2011
2012
2013
2014
2015
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Business Name
*
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Business Address
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Business Phone
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Website
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Brief Description of Business
*
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Loan Purpose
*
Give a brief description of what the loan would be used for?
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Loan Requested
*
$
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Startup
*
Yes
No
Is your business a Start-up (under 2 years old)?
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Financial Projections
Yes
No
If your business is a start-up do you have a business plan with financial projections?
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Total Cost of the Project
$
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Equity in the Business
$
Funds coming from your personal resources or raised from other investors
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Tax Lien
*
Yes
No
Do you have an existing tax lien?
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Years of experience in the industry
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Gross Sales
$
For the most recent fiscal year
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Business Expenses
$
Cost of goods sold, rent, salaries, utilities, etc for the most recent fiscal year.
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What is your current business debt?
$
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Guarantor
*
Yes
No
If needed, could you provide a guarantor?
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Full Name
*
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Address
*
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City
*
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State
*
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Zipcode
*
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Household Income
*
$
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Income from business
$
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Other Income
$
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Credit Score
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Home Phone
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Mobile Phone
*
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Email Address
*
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Bankruptcy
*
Yes
No
Have you declared bankruptcy in the past two years?
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How much are your monthly household expenses?
*
$
(Include rent, mortgage, utilities, credit cards, and monthly loan payments)
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Credit Cards
*
$
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Mortgage
*
$
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Other Loans
*
$
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Zipcode
Business Zip
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State
Bus. State
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City
Bus. City
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Gender
*
Male
Female
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Origin
*
White Non Hispanic
African American
Hispanic
Asian
Other
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Business Legal Entity
Sole Proprietorship
S Corporation
LLC
Corporation
Partnership
Other
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Collateral (Assets that can be pledged as guarantee)
These may include vehicles, equipment or real estate. Please list the item and dollar value.
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Number of owners
With 20% or more stake in the business
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Personal Information
