Loan Intake Form
First Name
*
Last Name
*
Street Address
*
City
*
State
*
Zip Code
*
County
Email
*
Mobile Phone
*
Home Phone
Gender
Male
Female
Date of Birth
Race
African
African American/Black
American Indian/Alaskan Native
Asian
Caucasian/White
Hispanic/Latino
Indian
Middle Eastern
Multi-racial
Native Hawaiian/Pacific Islander
Other
Race - Other
Ethnicity
Hispanic/Latin@
Not Hispanic/Latin@
Education
Grade School
High School Graduate/GED
Associate's Degree/Vocational Certificate
Bachelor's Degree
Post Graduate Degree
Marital Status
Single
Married
Separated
Divorced
Widowed
Domestic Partnership
Other
Military Status
Non-Vet
Active Duty
Reserve or National Guard
Service Disabled Veteran
Veteran
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?
Yes
No
Are you a US citizen or legal resident?
Yes
No
What is the primary reason you are seeking support?
*
Business Accounting/Budget
Business Plan
Buy/Sell Business
Cash Flow Management
Customer Relations
eCommerce
Financing
Franchising
Government Contracting
HR/Managing Employees
International Trade
Legal Issues
Managing a Business
Marketing/Sales
Start-up Assistance
Tax Planning
Technology/Computer
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
*
Sole Proprietorship
S-Corporation
B-Corporation
Corporation
Partnership
LLC
Other
Type of Business
*
Accommodation & Food Services
Administrative & Support
Agriculture, Forestry, Fishing & Hunting
Arts, Entertainment & Recreation
Childcare
Construction
Educational Services
Finance & Insurance
Health Care & Social Assistance
Information & Technology
Management of Companies & Enterprises
Manufacturing
Mining
Professional, Scientific & Technical Services
Public Administration
Real Estate, Rental & Leasing
Retail Trade
Transportation & Warehousing
Utilities
Waste Management & Remediation Services
Wholesale Trade
Other Services
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?
What benefits do you offer your employees (mark all that apply)?
Health Insurance
Retirement
Paid Time Off
Life Insurance
Paid Holidays
Loan Information
Requested Loan Amount (Enter Numbers Only)
*
Minimum $ amount needed (Enter Numbers Only)
*
How soon are funds needed?
*
Purpose of funds
*
Equipment
Working Capital
Refinance
Leasehold Improvements
Would you like to receive our e-newsletter?
Yes
No
How did you hear about WomenVenture?
SBA District
SBA Website
WBC
Lender
Advertisement
WomenVenture Website
Internet Search
Social Media
Word of Mouth
SCORE
Other
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
*