Loan Assistance Intake Form

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LOAN ASSISTANCE/CAPITAL ACCESS SERVICES REQUEST - EXISTING BUSINESS

Loan Application Assistance Request

Please complete the following information about the credit needs for your existing business

We will use this information to recommend the right solutions as assist you.

Basic Business & Contact Person Information

                                                                          First Name:
                                                            Last Name:
                                                              Company:
                                                                    Email:
                                                                     Fax:
                                                               Address:
                                                                     City:
                                                      State/Province:
                                                                      Zip:

Business structure:

Industry:

Gross Annual Business Revenue:

                                              No. of Employees:

                                                 Years in Business:

Referred By: (person)
from (Organization)

Business Ownership Information

Select Ethnicity of Business Ownership (51% or more):

Gender:

Tell Us About Your Financing Needs

Loan Amount Sought:

Loan Purpose ( select all that apply):

New Business Start-up Business or Franchise Acquisition

Acquire Equipment/Fixed Assets Inventory or Receivable Funding

Building Purchase or Building Improvements Business Credit Cards/Trade Credit

Term loan for General Operating Costs Expansion Funds

Explain any other specific credit needs:

What type of collateral can you pledge?

Have you ever been denied for a loan? Yes No

                                                 Tell us the reasons for prior loan denial:
                                                                     Who were you denied by:

For Internal Processing Purposes Only - Do Not Complete:

                                                         FFIEC Geo-coding:

                                                                                       Internal Use Only: