Your Name:

Business Name:

Mailing Address:

City:

State:

Zip:

Country:

E-mail address:

Telephone:

Fax:

Cell phone:

Industry / Type of Business:

Form of Business:
Sole Proprietorship Partnership Corporation

Number of years in business:
Pre-Venture start-up (< 3 years) 3 -10 Years >10 years
 

Do you have employees?
Yes No

If so how many?
1 part time >1 part time > 1 Full time 1 full time
 

Type of Technical Assistance sought:
Accounting Business Growth Business Strategies Coaching (business) Customized Computer Software Computerized Bookkeeping Financial Planning/Management Graphic Design Legal Loan Development Marketing Research Marketing Strategy Marketing and Promotion Web Design
 

Are you employed part or full time?
Part time Full time

Are you seeking a business loan?
Yes No

If yes, would this funding :
Hold down CTRL key to select multiple items
  Create additional jobs / hire employees Grow Your Business Puchase new and/or additional equipment Start / Stay in Business
 

Other pertinent data for this application: