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First Name
Last Name
Email Address
Loan Amount
$
Business Name
Business Zip Code
Loan Purpose
Select Loan Purpose
Advertising/Marketing
Build Credit
Building Improvements
Business Acquisition
Cash Flow/Working Capital
Commercial Loan/Refi
Commercial Vehicle
Computer/IT
Debt Consolidation
Insurance
Inventory Purchase
Investment
Education/Training
Equipment Purchase
Expansion/Relocation
Franchise Funding
Furniture/Fixtures
Large Purchase
Materials/Supplies
P.O. Financing
Pay Bills/Taxes
Pay Rent/Mortgage
Payroll/Hire Employees
Professional Fees
Starting a Business
Telecommunications
Transportation/Shipping
Travel/Tradeshow
Unexpected Expense
Other
Business Type
Select Business Type
Accounting & Bookkeeping
Administration & Support
Advertising/Marketing
Air Conditioning
Architectural/Engineering
Arts & Entertainment
Auto Dealer/Sales
Auto Service & Parts
Automotive Repair
Bar/Night Club
Beer, Wine, Liquor Stores
Building Materials
Catering
Cleaning Services
Clothing Store
Construction
Convenience Store
Courier/Messenger
Day Care Services
Direct Sales
Educational Services
Electronics & Appliances
Equipment Contractor
Financial & Credit Services
Florist
Funeral Services
Gas Station/Convenience
Grocery Store
Hair Salon
Health Care Services
Hobby, Book & Music
Home Improvement
Home Services
Hotel & Hospitality
Information & Computer
Insurance Services
Interior Design
Labor/Political Org
Landscaping Services
Laundry/Dry Cleaning
Legal Services
Management Consulting
Manufacturing
Mining
MLM
Moving/Storing
Non Profit
Personal Care Services
Pharmacist
Physician/Dentist
Plumbing
Printing/Publishing
Professional Services
Real Estate
Recreation & Amusement
Religious/Civic
Repair & Maintenance
Restaurant & Food
Retail - Gift
Retail - Offline Misc.
Retail - Online Misc.
Scientific & Technical
Security Services
Social Services
Specialty Trade
Specialty Trade Contractor
Telecommunications
Transportation Services
Trucking
Veterinarian
Warehousing
Wholesale/Distribution
Other
Years Owned
Select Years Owned
Still in planning stages
Less than 5 months
5 months to 1 year
1 year
2 years
3-4 years
5-9 years
over 10 years
Annual Revenue
Select Annual Revenue
$0 - $34,999
$35,000 - $49,999
$50,000 - $99,999
$100,000 - $249,999
$250,000 - $499,999
$500,000 - $999,999
$1 Million - $5 Million
Over $5 Million
Profitability
Select Profitability
Profitable
Breakeven
Not Profitable
Monthly CC Sales
Select Monthly CC Sales
Do not accept Visa/MC, or less than $1,700
$1,700 to $2,499
$2,500 to $4,999
$5,000 to $9,999
$10,000 to $24,999
$25,000 to $99,999
$100,000 or more
Business Bank Balance
Business Bank Balance
Do not have a business account
$0 - $1,699
$1,700 - $2,999
$3,000 - $4,999
$5,000 - $9,999
$10,000 - $50,000
$50,001 and up
Credit Rating
Estimated Credit Score
Excellent (750+)
Very Good (700-749)
Good (660-699)
Fair (600-659)
Poor (599 or lower)
Ever Declared Bankruptcy
Ever Filed Bankruptcy?
No
No, currently considering
Yes, currently in process
Yes, discharged less than 1 year
Yes, discharged between 1-2 years
Yes, discharged between 2-7 years
Yes, discharged between 7-10 years
Yes, discharged over 10 years ago
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