Name
*
First Name
Last Name
Phone
(###)
###
####
Email
*
Business Zip Code
*
Business Name
*
Year Founded
*
Did this business employ anyone other than the owner?
*
I am:
*
Industry
*
Agriculture and farming
Arcade
Auto repair
Beauty services
Car dealership
Construction
Convenience store
Dry cleaner
Education service provider
Financial services
Grocery store
Gym or sport recreational facility
Health service provider
Hospitality (hotels and motels)
HVAC
Insurance
Leisure
Manufacturing
Performing Arts venue
Professional services
Plumbing
Restaurant and/or Bar
Transportation
Other
Business Structure
Sole Proprietorship
Partnership
Limited Liability Corporation
S-Corporation
C-Corporation
Cooperative
Other
Amount Needed
*
Uses of capital
*
Examples: Building lease, inventory, staff expenses etc, be as specific as possible.
Term Desired
*
Less than one year
2-5 years
6-10 years
Was this business interrupted?
*
Currently Operating?
*
Website link, if still active
*
Reason for interruption
Was it a named event?
(i.e. Hurricane Helene, Hurricane Milton, Hurricane Maria, Los Angeles Wildfire, Eaton Fire, Central Texas Guadalupe River flooding, Mauna Loa Eruption, etc.)
What social media do you use for business?
Please select all that apply
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