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Prefix First Name Last Name Suffix

Company Name Email Address

Business Telephone Cellular Phone

Company Street Address

City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code

Company Mailing Address

City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code

Type of Business Years You Have Owned Business

Company Website (if any) Number of Employees

Ownership Percentage (You and Spouse) Is your business incorporated or an LLE?

Average Visa/MC Credit Card Sales/Month (past year) Name of Credit Card Processing Company

Total Sales Per Year Lease Expiration Date for Business

Amount of Funds Being Requested ($20,000 to $300,000) When do you need funds? (Next week, month, etc.)

How much of the amount requested do you want to use for the purchase or lease of equipment? How long do you intend to continue owning your business? 1 Year 2 Years More than 2 Years

Are there any judgments against you or your business? Are there any liens against you or your business? Yes No If yes, please explain, including amount Yes No If yes, please explain, including amount

Have you filed for bankruptcy in the past ten years? Yes No Any intentions of filing bankruptcy in next 18 months? Yes No

How did you find us? Referral Person’s Name Referral Person’s Email Address

Comments

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If you want a regular commercial loan, then click here: Commercial Loan