I. Who is making the referral?
Organization Name:
Your Name:*
Your Email Address: *
Your Telephone:
II. Who is being referred?
Please tell us about the client:
Name:
Business Name:
Address:
City:
County
State:
Zip:
Telephone:
Cellular/Alternate Number:
Fax Number:
Website:
Email:
Industry:
Best time to contact the client:
Morning
Afternoon
III. Requested Loan Information
Please tell us a little more so that we are able to better serve the client.
This client is a/an:
Pre-Start-up business (less than one year)
Start-up business (between 1 and 2 years)
Established business (more than two years)
Amount of financing needed:
IV. Loan Purpose
Please choose the following options to help us understand how the client will use loan funds. Check all that apply.
Working Capital
Inventory
Furniture
Equipment
Partnership Loan
Fixtures
