LOAN PRE-APPLICATION FORM - Nebraska Enterprise Fund

Business Name and DBA *

Key Contact/ Authorized Representative/ Title *

Applicant Home Phone Number (no dashes/spaces)

Applicant Cellular Phone Number (no dashes/spaces) *

Co-Owner Information (If Applicable)

Name of co-owner or spouse, % of business owned, SS #, Occupation (If Applicable)

Business Address *

Include street, city, state, ZIP, and county

City *

State *

Zip Code *

Business Ownership Structure *

If *Other ownership structure; please specify

Federal ID#

DUNS #

Business Start Date *

Email *

Website

Business Industy *

Owner's Experience and/or Training related to business *

Typed Signature (in lieu of a written signature) *

I request business assistance in the form of a micro-loan, training, and/or business technical assistance or counseling from the Nebraska Enterprise Fund or one or more of its program partners. I agree to participate should I or my business be selected to participate in follow-up surveys designed to evaluate NEF or its partner services. I understand that any information disclosed will be held in strict confidence by NEF staff, the NEF loan committee and by any NEF resource partner. In consideration of the counselor(s) working for NEF or its partners furnishing management or technical assistance, I waive all claims against NEF personnel, and that of its resource partners and host organizations, arising from this assistance.