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 a member of your family a veteran? *

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 (copy)

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

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.