Questionnaire for Services - Nebraska Enterprise Fund

Name *

First

Last

Address *

Include street, city, state, ZIP, and county

City *

State *

Zip Code *

Email *

Cell Phone Number (no dashes/spaces) *

Gender *

Race *

Ethnicity *

Country of Origin *

Example: United States

Do you already have a business established? *

Business Name and DBA

Please enter N/A if not established yet.

How did you hear about Nebraska Enterprise Fund? *

What is your current credit score range? *

Are you or an immediate family member a veteran, a National Guard or Reserve member, or a military spouse? *

If you answered yes above:

You will be directed to an external website after your submission below that is managed by the Small Business Association’s (SBA) Veterans Business Outreach Center (VBOC), where you will signup for a new account with the SBA-VBOC NEOSERRA Platform. A Nebraska Enterprise Fund VBOC team member will be reaching out to you after your submission.

What Services are you looking for? *

If Requesting Capital (Business Loans) *

Please describe the capital amount requested List loan purposes /uses by $ amount. FOR EXAMPLE: $ 20,000 for Purpose: Working Capital & Equipment What is the minimum amount you can work with and what will the purpose be $ for Purpose?

Notes

Please let us know if you have other questions or needs.

Do you Agree to Complete a Prequalification Soft Credit Pull? (Submitting this will NOT impact your credit score) *

Submitting this form will NOT impact your credit score. I hereby authorize Nebraska Enterprise Fund to access my credit report on the date below for purposes of providing me with financial counseling and for inclusion in depersonalized/anonymized data within Member Outcome Reporting used to track aggregate consumer financial progress. I understand that this inquiry into my credit constitutes a “soft inquiry” and will not adversely affect my credit or credit rating. While this credit report and score pulled by Nebraska Enterprise Fund on my behalf will be used to provide me with financial counseling, it is understood that I will not receive a copy of this credit report. Notwithstanding the foregoing, I understand that I have the right to dispute information with the credit bureau, to request reinvestigation, and to have corrected reports reissued to previous recipients of this credit report, if warranted. I understand that credit information is sensitive and that there may be inherent risks to accessing such data; I have had the opportunity to ask the Nebraska Enterprise Fund staff any questions regarding such risks. I further understand that all my personal information will be held confidential by Nebraska Enterprise Fund.

Date of Birth *

Social Security Number *

Signature *

Clear 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.