Business Information

* Required Information

Legal Business Name *

Date Established

Street Address *

City *

State *

Zip Code *

Office Phone *

Primary Contact First Name *

Primary Contact Last Name *

Primary contact Mobile phone to receive text messages from lender *

Email Address *

Website Address

Fax Number

Legal Status *

NAICS Code

Number of Employees *

Description of Business *

Federal or State Taxes Past Due? *

Yes

Type

Have you or any other entities affiliated with you ever filed for bankruptcy? *

Yes

Year

Tax Lien Filed?

Yes

Year

Minority Status of the Firm (Check all that apply):

African American

Hispanic American

Asian American(inclides Asian-Indian and Asian-Pacific individuals)

Native American

Certifying Regional Council *

OFFICERS, OWNERS, OR PARTNERS

(With 20% ownership interest of more) if owner is an LLC or trust, add the managing member or trustees in the ownership field below

Owner

Name and Title

% Owned

Driver's License #

Home Street Address

Home Owned or Rented?

Own

Rent

City

State

Zip Code

Cell Phone *

Email Address *

Date of Birth *

Social Security # *

Are you a citizen or legal resident of the United States? *

Current Business Debt

Lender	Loan Type	Current Balance	Monthly Payment	Maturity Date

Corporate Member

Name of NMSDC national or local corporate member Applicant either (i) is selling products or providing services to, or (ii) has sold products or provided services to within the last twelve (12) months:

Revenue from Corporate Member within the last 12 Months:

Name:

Phone:

Email:

Please Provide

	Projected Current Year	Last Year	2 Years Ago	3 Years Ago
Revenue *
Net Income/Loss *
Total Assets
Total Liabilities
Equity

Amount of financing requested: *

Use of Proceeds:

Working Capital:

Inventory:

Furniture/Fixes:

Debt Refinancing:

Equipment:

Leashold Improvements:

Other:

How many new jobs will be created as a result of this financing? *

Terms and Conditions

PLEASE INITIAL BELOW:

* As an authorized representative I submit this pre-application for a loan to the Business Consortium Fund, Inc. (BCF) and subsidiaries. I authorize BCF to make inquiries as necessary to verify the accuracy of the statements, and should it be required; I will provide additional information to determine the creditworthiness of the individual owners listed above.

Initial Here:

Print name and title:

Date:

Any loan application that results from this inquiry will not be considered complete without a non-refundable application fee of $350.00