Legal
name of business (if different)
State
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Does your
business presently accept credit cards?
Select Response
Yes
No
*
Monthly VISA®
/ MasterCard® Sales
Select Monthly Volume
None
$1-$2,499
$2,500-$4,999
$5,000-$7,499
$7,500-$9,999
$10,000-$12,499
$12,500-$14,999
$15,000-$19,999
$20,000-$24,999
$25,000-$29,999
$30,000 +
*
Amount your
business would like to borrow
Select Loan Amount
$10,000
$15,000
$20,000
$25,000
$35,000
$50,000 +
*
Total Monthly
Sales (all types)
$
Date your
business was established
Choose Month
January
February
March
April
May
June
July
August
September
October
November
December
Choose Year
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
*
Type of Legal Entity
Choose One
Corporation
Limited Partnership
General Partnership
Limited Liability Company
Sole Proprietorship
*
State of Incorporation
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Choose your
Industry Category
Choose One
Auto Repair & Service
Beauty
Computers
Construction
Flowers & Gifts
Gasoline
Health & Fitness
Manufacturing
Professional Services
Real Estate
Restaurant
Retail
Sporting Goods
Trucking
Wholesaler/Distributor
Other
How is your
Personal Credit?
Choose One
Don't Know
Poor
Fair
Excellent
*
Intended
Use of Funds
Choose One
Advertising
Cash Flow
Debt Consolidation
Inventory
Equipment Purchase
Expansion
Payroll
Remodeling
Working Capital
Other
*
How did you
hear about us?
Choose One
AOL
Direct Mail
Don't Remember
Google
MSN
Other
Phone Call
Word of Mouth
Yahoo
*
Anything
Else You Would Like to Add? (200: character
maximum)