BUSINESS INTAKE FORM

AFFILIATE NAME:

FIRST NAME:

LAST NAME:

EMAIL:

PHONE NUMBER:

LEGAL ENTITY NAME(IF APPLICABLE):

ENTITY:

SOLE OR PARTNERSHIP (ADD SPLIT % IN "OTHER") IF APPLICABLE:

STATE OF INCORPORATION:

YEAR OF INCORPORATION:

TIME IN BUSINESS:

INDUSTRY:

ANNUAL SALES:

REQUESTED FUNDING AMOUNT:

USAGE OF FUNDS:

HOW SOON NEEDED:

BORROWER FICO SCORE:

BANKRUPTCIES, LEINS OR REPOSESSIONS:

ANY CHARGE OFFS/LATE PAYMENTS LAST 2 YEARS:

ANY LOANS TAKEN OUT WITHIN PAST 2 YEARS:

ANY ADDITIONAL INFO:

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326 Penn Ave

West Reading, PA 19611