Intake Form SIF

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Intake Form SIF

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Trade Name of Business*
Legal Name of Business*
Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Municipality*
County*
Date Business Established*
State Business Incorporated*
Tax ID Number (EIN)*
Does the Business operate outside of Pennsylvania*
- Yes
- No
Has the business received assistance from a Small Business Development Center or another economic service provider?*
- Yes
- No
Is the business located in an abandoned or underutilized building or site?*
- Yes
- No
Business Industry*
- Manufacturing
- Research & Development
- Developer
- Agriculture
- Construction
- Child Daycare
- Industrial
- Service Enterprise
- Energy
- Defense Conversion
- Hospitality
- Other
Legal Structure*
- Sole Proprietorship
- Limited Liability Company
- C-Corporation
- Partnership
- S-Corporation
LOAN REQUEST INFORMATION
Amount Requested*
Proposed Collateral*
Current Full Time Employees*
- Fewer than 100
- 101-250
- 251 or Greater
Current Part Time Employees*
- Fewer than 100
- 101-250
- 251 or Greater
Projected new Full Time Employees within 3 years of Financing*
- Less than 10
- 11-50
- 51 or Greater
Projected new Part Time Employees within 3 years of Financing*
- Less than 10
- 11-50
- 51 or Greater
Will jobs be lost without financing?*
- Yes
- No
Purpose of the loan*
- Land or Building Acquisitions
- Working Capital costs
- Construction and Renovation
- Machinery or Equipment
- Other, please explain:
Brief history of your organization, how has it grown, and how do you plan to grow with the new financing.*
What benefit does your company offer the community?*
BUSINESS OWNERSHIP
List*
Provide names and percentages of ownership for each person owing at least 20% of the business. If no one person owns at least 20%, list the information for the five people who own the largest shares or hold the highest position.
Name Title/Position % of Business Owned Years with the Business

Name	Title/Position	% of Business Owned	Years with the Business

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Intake Form SIF

LOAN REQUEST INFORMATION

BUSINESS OWNERSHIP