In less than ten minutes you should be able to complete our short and focused application. You can either submit it online below, or print the PDF version (requires Adobe Acrobat Reader) and fax it to 248-000-0000. Based on this information, you will receive a quick response, followed up by a call from a representative by 11:00 AM the next business day.

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1: Company Name:
2: Trade Name:
3: Address:
4: City:
5: State:
6: Zip:
7: Telephone:
8: Fax:
9: E-mail Address:
10: Principal Executive Officer (CEO/President/Owner):
11: Person Completing Application (with Title):
12: Industry:	Select One HealthCare Services -- AcuteHealthCare Services -- Long Term CareHealthCare Services -- OutpatientHealthCare Services -- OtherTelecommunications -- ServicesTelecommunications -- DistributionBusiness ServicesStaffingManufacturing -- BasicManufacturing -- TechnologyDistribution -- BasicDistribution -- TechnologyMedia and EntertainmentRetailRestaurantConsultingTechnology -- ISPTechnology -- ASPTechnology -- InternetReal EstateFinancial ServicesInvestment ManagementOther
13: Amount of Financing Requested:	Select One 0-$1,000,000 $1,000,000 - $5,000,000 $5,000,000, - $10,000,000 $10,000,000 - $15,000,000 $15,000,000 - $20,000,000 $20,000,000 - $25,000,000 $25,000,000 - $30,000,000 Over $30,000,000
14: Why do you need financing:	Select One For general working capital needs To finance growth To finance an acquisition To finance a buyout To finance a recapitalization event To refinance existing debt To buy equipment To buy real estate Other
15: What type of financing do you need?	Select One Debt - General or Senior Debt - Cash Flow Based Debt - Asset Based Debt Equipment Financing Debt - Mezzanine Equity (venture capital or private equity) A Combination of some of the above Other
16: When was your business started?	Month Day Year (4 digits) Select JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Select 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
17: Is it a private or public company?	Select One private public
18: If public, stock symbol?
19: Do you have investors?	Select One Yes No
20: If yes, what type?	Select one Venture Capital Private Equity Individuals
21: If yes, how much has been invested in the company:	Select One 0-$1,000,000 $1,000,000 - $5,000,000 $5,000,000, - $10,000,000 $10,000,000 - $15,000,000 $15,000,000 - $20,000,000 $20,000,000 - $25,000,000 $25,000,000 - $30,000,000 Over $30,000,000
22: Do you have any other debt?	Select One Yes No
23: If yes, what type?	Select One Bank Debt Commercial Finance Company Debt Investor Debt High Yield Debt Public Debt
24: If yes, how much?	Select One 0-$1,000,000 $1,000,000 - $5,000,000 $5,000,000, - $10,000,000 $10,000,000 - $15,000,000 $15,000,000 - $20,000,000 $20,000,000 - $25,000,000 $25,000,000 - $30,000,000 Over $30,000,000
25: How many employees do you have?
26: How many offices do you have?
27: Has the company ever filed for bankruptcy protection?	Select One Yes No
Please fill in the following amounts (use whole dollars only without punctuation, enter "0" if item has no amount, e.g., 55923 or 0): Most Recent Period    Select Month Three months Most Recent Year Assets: 28: Cash 29: Accounts Receivable 30: Real Estate 31: Equipment 32: Other   Liabilities: 33: Loans 34: Trade Debt   Equity: 35: Total   Revenue: 36: Total   Expenses: 37: Operating Expenses 38: Non cash expenses (depreciation & amortization)   Cash Flow: 39: Total   Pre-tax Income/Loss 40: Total
41: Has your revenue increased over the last three years?	Select One Yes No
42: Has your net income increased over the last three years?	Select One Yes No
43: Do you have audited financial statements?	Select One Yes No

44: You can attach an electronic file containing your full financial statements here (optional). Please submit only MS Word, MS Excel, or plain text files. If you have multiple files, please put them in a single ZIP file first.


45: Please tell us anything else you would like us to know about your business--please limit to 500 characters (optional):

Please check that all required fields are filled in before submitting the form.