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Referral Information

Please provide your information




Please ensure that no extra space is added before or after the valid email address.

Business Information
Please provide the Legal Name under which your business is registered.
If your Business operates under a name different than your Business Legal Name, then this field is required.








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Please enter date MM/DD/YYYY.
Business Address

If your address includes an apartment number, please use the abbreviation "Apt" without additional punctuation or symbols. Example: Apt 123.



Business Address Zip Code






Personal Information





Your answer will help us to provide you with the correct loan product(s).

Please ensure that no extra space is added before or after the valid email address.



Home Address

If your address includes an apartment number, please use the abbreviation "Apt" without additional punctuation or symbols. Example: Apt 123.



Business Ownership


Other Owner Information





Home Address

If your address includes an apartment number, please use the abbreviation "Apt" without additional punctuation or symbols. Example: Apt 123.



Loan Information


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Use of Proceeds
Please provide an estimate of the use of proceeds for each category below.

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Collateral

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Please provide an estimate of each type of collateral available for this loan request.

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Business Interview














Optional Owner Demographics
Disclosure of this information is voluntary and has no bearing on the credit decision. This data is collected for program reporting purposes. The information provided will remain confidential and will be reported as borrower aggregate statistics, not individual data. This information helps Business Impact NW to improve its delivery of service and allows us to better fulfill our mission.


Please provide a short description








Financial Information
This section requires detailed financial information, and you may want to gather the following documentation before starting.

*Most recent tax return
*Current savings, checking, retirement, and other investment account statements
*Recent mortgage statements
*Documentation of the value of personal assets

Estimate of Assets


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Estimate of Liabilities



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Monthly Income and Expenses


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Terms and Conditions
This loan application is a request for services from Business Impact NW, an SBA resource partner, and therefore the applicant authorizes Business Impact NW to make inquiries necessary to verify the accuracy of the statements made to determine creditworthiness.  The applicant certifies, under penalty of law, that all information provided in conjunction with this application is complete, true and correct to the best of their knowledge. 

The applicant understands that relevant information from this application will be furnished to the assigned loan officer(s) and/or business counselor(s) within Business Impact NW.  The applicant further understands that Business Impact NW personnel agree 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 staff member furnishing management or technical assistance, the applicant waives all claims against Business Impact NW and/or SBA personnel arising from this assistance. 


Confidentiality Agreement

This application also acts as a Confidentiality and Code of Conduct Agreement.  Any information disclosed will be protected to the extent permitted by law (This organization and/or the SBA or its agents will not provide your personal information to commercial entities.).  Your information will help Business Impact NW and the SBA's continuing improvement of business counseling programs, to ensure effective oversight and management of entrepreneurial development programs and grants, and to meet Congressional and Executive Branch reporting requirements.
Form ID 4961724 v0.12
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