First Name *

Last Name *

Company Name *

Work Phone *

E-Mail *

Address 1 *

City *

State/Province *

Postal Code *

Although the fields below are not required, the more information you provide, the better able we will be to assist you. Please answer all questions to the best of your knowledge. Please note that all information you provide will be considered proprietary and confidential.

Why do you want to start a business?

How much funding will your business require to start (estimate)?

Describe your business idea and the types of products and/or services you will offer:

Do you have any collateral (real estate, inventory, equipment, vehicle, CDs, stock)? If Yes, please identify the type of collateral in the extra text field provided.

Yes

No

When do you plan to start the business (month, year)?

Please estimate your first-year sales?

How do you plan to finance the start-up of your business?SavingsBank Loan/Line of CreditHome Equity LoanInvestorsFriends/RelativesI don’t require financing at this timeother

If you require financing, what will the money be used for?

How much money do you have available to invest in the business?

What is your current occupation?

Marital StatusSingleMarried

Do you have a current copy of your credit report? (if “Yes,” please bring it to your initial meeting)YesNo

What is your current credit score?

What is your current annual household income?

Which legal structure are you considering for the business (choose only one)?Sole ProprietorshipPartnershipCorporationLimited Liability Company (LLC)Limited Partnership (LP)Note sure/Need advice

Have you registered the name of your business?YesNo

Do you currently have a draft of your business plan?YesNo

Have you filed for bankruptcy within the past ten years?YesNo

Do you have a CPA or accountant?YesNo

Do you have a lawyer?YesNo

Have you ever started or owned a business before?YesNo