Loan Intake Form

 
First Name*
 
 
Last Name*
 
 
 
Street Address*
 
 
 
City*
 
 
State*
 
 
 
Zip Code*
 
 
County
 
 
 
Email*
 
 
 
Mobile Phone*
 
 
Home Phone
 
 
 
Gender
 
 
Date of Birth
 
 
 
Race
 
 
Race - Other
 
 
 
Ethnicity
 
 
Education
 
 
 
Marital Status
 
 
Military Status
 
 
 
Do you identify as LGBTQ?
 
Yes
No
 
 
Do you have a disability?
 
Yes
No
 
 
 
What is your annual personal income?*
 
 
 
What is the total income of your household in one year?*
 
 
 
How many adults (including you) are in the household?*
 
 
 
How many children 17 and under in the household?*
 
 
 
Are you head of household for tax purposes?
 
 
 
Are you a US citizen or legal resident?
 
Yes
No
 
 
What is the primary reason you are seeking support?*
 
 
 
 
 
 
 
 

Business Information

 
Business Name*
 
 
 
Doing Business As
 
 
 
Are you currently in business?*
 
Yes
No
 
 
Business Start Date
 
 
 
Is your business registered with the state?*
 
Yes
No
 
 
Do you have a completed business plan?*
 
Yes
No
 
 
Legal Entity*
 
 
 
Type of Business*
 
 
 
Description of Business*
 
 
 
Business Owner Names*
 
 
 
Street Address*
 
 
 
Address 2
 
 
 
City*
 
 
 
State*
 
 
Zip Code*
 
 
 
Business County
 
 
 
Business Phone*
 
 
 
Business Email*
 
 
 
Website
 
 
 
NAICS Code
 
 
 
% Woman-owned*
 
 
 
Full-time Employees*
 
 
 
Part-Time Employees*
 
 
 
Total employees*
 
 
 
What is your average employee wage? (Not including the owner, please leave blank if the owner is the sole employee)
 
 
 
For the most recent full business year, what were your gross revenues/sales?*
 
 
 
For the most recent full business year, what was your owner annual compensation or draw?*
 
 
 
For the most recent full business year, what were your +profits/- losses?*
 
 
 
Do you conduct business online?*
 
Yes
No
 
 
Is your business home-based?*
 
Yes
No
 
 
Is your business 8(a) certified?*
 
Yes
No
 
 
Is your business WBE certified?*
 
Yes
No
 
 
Are you an exporter?*
 
Yes
No
 
 
If yes, how many of your employees are involved with exporting?
 
 
 
 
 
Health Insurance
 
 
 
 
Retirement
 
 
 
 
Paid Time Off
 
 
 
 
Life Insurance
 
 
 
 
Paid Holidays
 
 
 
 
 
 

Loan Information

 
Requested Loan Amount*
 
 
 
Minimum $ amount needed*
 
 
 
How soon are funds needed?*
 
 
 
Purpose of funds*
 
 
 
 
Would you like to receive our e-newsletter?
 
Yes
No
 
 
How did you hear about WomenVenture?
 
 
 
  • I understand that by signing this form, I consent for WomenVenture to pull my credit.
  • I understand WomenVenture (“WV”) does not allow: distribution of contact information of staff, clients or volunteers; provision of fees for transportation, childcare or psychological services; assault or harassment of or by clients; disruptive behavior; participation in programs while under the influence of illegal drugs or alcohol.
  • I understand WV will maintain confidentiality of client information and business ideas, and that this information may be included in confidential reporting to funding agencies. I agree to maintain the confidentiality of any business ideas and plans learned from classmates.
  • for any injury to me resulting from my business decisions.WomenVentureI understand that while WV may consult on business concerns, clients are responsible for business decisions and the results. I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur in making business decisions. I release, waive and forever discharge any and all claims against
  • I understand that clients may be photographed or videotaped at WV events, programs and meetings; and that these photos and videos may be used by WV or the Small Business Administration (“SBA”) for marketing purposes. WV will honor client requests to not have one’s image used.
  • I request business counseling service from the SBA or an SBA Resource Partner. I agree to cooperate in surveys designed to evaluate SBA or WV services. I permit SBA and WV the use of my name and address for surveys and information mailings regarding their products and services. I understand any information disclosed will be held in strict confidence. SBA and WV will not provide your personal information to commercial entities. I authorize SBA to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(s) agrees not to: 1) recommend goods or services from sources in which he/she has an interest, and 2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, and that of its Resource Partners and host organizations, arising from this assistance.
  • Your signature certifies that the information on this form is accurate and indicates understanding and agreement to the statements listed above.
 
E-Signature (type name)*
 
 
Today's Date*