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Has your business generated revenues in the last 6 months? --None-- Yes No

What amount of funding are you seeking? --None-- $1,000 – $10,000 $10,001 – $25,000 $25,001 – $50,000 $50,001 – $100,000 Over $100,000

Can you provide business & personal tax returns for the past 3 years? --None-- Yes No

Is your business registered in the state where you are located? --None-- Yes No

How did you hear about VestedIn? --None-- BBEA B-Smart Honeycomb Business Association Web Search CDC Bank Referral Social Media VestedIn Newsletter VestedIn Staff Phila Commerce Dept. Black Squirrel SBA CDFI Referral WesGold Fellows Power Up Mom Your Business Event The Business Center SBDC Referral Other

Is your business in any of the following industries: Bar, Marijuana Related, Finance, Gambling, Adult Entertainment --None-- Yes No

Do you have collateral to cover the full amount of the loan (will not disqualify you if you don't)? --None-- Yes No

What is your credit score? --None-- Below 599 600 – 650 651 – 700 701 – 750 Above 750

Business Name Owner First Name Owner Last Name Owner Cell Phone Number Owner Business Email Business Street Business City Business State/Province Business Zip/Postal Code