Bankers Referral Form

I. Referral Bank Information
Please tell us who you are. (*required information)

*Bank Name:
*Your Name:
*Your Email Address:
*Your Telephone:
II. Prospective Client Information:
Please tell us about the client.

*Name:
*Business Name:
Address:
City:
State:
Zip:
*Telephone:
Cellular/Alternate Number:
Fax Number:
Website:
*Email:
Type of Business:
Other:

Best time to contact the client:
Morning
Afternoon

III. Requested Loan Information
Please tell us a little more so that we are able to better serve the client.

This client is a/an:
Start-up business (less that one year) requiring less than $15,000.
Established business (more than one year) requiring up to $50,000.

IV. Loan Purpose
Please choose the following options to help us understand how the client will use loan funds. Check all that apply.

Working Capital
Inventory
Furniture
Equipment
Partnership Loan
Fixtures

WARNING: Please review your information before submitting. Once you have clicked "Submit" you will not be able to change the information.

The Center is funded in part through a Cooperative Agreement with the U.S. Small Business Administration.
All opinions, conclusions, or recommendations expressed are those of the authors and do not necessarily reflect the views of the SBA