LOAN PRE-APPLICATION FORM - Nebraska Enterprise Fund

Business Name *

Key Contact or Authorized Representative *

Contact/Representative Title *

Home Phone Number *

Mobile Phone Number

Primary Email Address *

Co-Owner Information (If Applicable)

Co-Owner Name, Percentage of business owned, Occupation, their contact info (If Applicable)

Business Address *

City *

State *

Zip Code *

County *

Federal ID#

DUNS #

Business Ownership Structure *

If *Other ownership structure; please specify

Type of Business Activity *

Business Start Date

Owner's Experience and/or Training related to business

Number of Employees (excluding Owner)

Part-Time

Full-Time

FTE

Projected Change in Employees

Most Recent Gross Revenue/Sales

Overall Gross Revenue/ Sales from your most recent business year

Most Recent Business Profit/Loss

Overall Business Profits/Losses from your most recent business year

Is the Business seasonal?

Yes
No

Avarage Monthly Sales

Highest Month Sales

Lowest Month Sales

Current Business Assets

Owner Draw from Business

Does the business provide health insurance to the applicant?

Yes
No

Does the applicant have health insurance from another source?

Yes
No

Does this Business have a bank account?

Yes
No

Name of Banker

Enter your Bank Infromation

Bank

Savings Account

Checking Account

Does this Business currently have other bank loans?

Yes
No

If *YES, please list bank names and accounts:

Does this Business currently have outstanding credit card debt?

Yes
No

If *YES, please indicate the amount

Amount of Business Loan Requested *

Requested Loan Terms (in months)

List Loan purposes/uses by $ amount

What is the minimum amount you can work with and what will the purpose be?

What collateral will be available to secure this loan? List each item and its estimated value.

Please note: NEF requires personal guarantees to be provided from all owners with at least a 10% investment or stake in the business and may request other personal guarantors as needed.

Does the applicant or any principal of the business have any outstanding judgments, unsettled lawsuits, knowledge of potential lawsuits, tax liens, or other disputes or problems of a similar nature?

Yes
No

If *YES, please explain:

Has the applicant or any principal of the Applicant been involved in any bankruptcy or insolvency proceeding?

Yes
No

If *YES, please explain:

Please indicate type(s) of business assistance are you seeking from the Nebraska Enterprise Fund or one or more if its program partners:

Loan
Training
Business Technical Assistance
Business Counseling

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 NEF’s resource partner for loan underwriting. 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.

Typed Signature (in lieu of a written signature) *