Startup Loan Assistance Request Form

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LOAN ASSISTANCE/CAPITAL ACCESS SERVICES REQUEST - NEWLY STARTED BUSINESS

Loan Application Assistance Request

Congratulations on the start-up of your new business!

Please input the following information about the credit needs for your new start-up business. We will use this information to recommend the right solutions to assist you.

Basic Business & Contact Person Information

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

Business structure:

Industry:

Projected 1st Year Gross Revenue:

                    No. of Employees in 1st Year of Business:


                                                 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:

Financing Categories ( 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: