Business Name*
Business Address*
First name*
Last name*
Is this contact an owner with 20% equity or more?*
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Business phone*
x
Cell phone*
Email address*
Rent or Own Business Property?*
*
Monthly Rent/Mortgage*
EIN/SSN*
Date Business Established*
Primary Industry*
*
Ownership Structure*
*
If Other, please specify
Name of Owners with 20% equity or more
Owner 1
First name
Last name
Owner Address
Owner 2
First name
Last name
Owner Address
Owner 3
First name
Last name
Owner Address
Owner 4
First name
Last name
Owner Address
Please provide Small Business Emergency Loan Application documentation.
Last year gross sales*
Last year net earnings*
Number of Employees (Full Time Equivalent)*
Monthly fixed expenses*
Reason and Purpose for Loan*
Amount Requested*
Have you filed for bankruptcy within the past ten (10) years?*
*
Are there any outstanding judgments entered against you?*
*
Are you presently a party to any lawsuits?*
*
Are there any local, state or federal tax liens filed against you?*
*
Are you current with all local, state, and federal taxes?*
*
Signature*
I understand that making a false statement on this form is a violation of law and could result in criminal prosecution, significant civil penalties, and a denial of the loan.*
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I also understand that there will be $350 application and filing fee.*
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Please verify that you are a real person*