Business Intake Form

Medical Professionals and Small Businesses Not For Investor Transactions

Loan Purpose
Other
Have you submitted an application for COVID-19 relief funding through the SBA or another organization?
- Yes
- No
Do you Have Any Of The Following?*
- Back Income Taxes
- Back Payroll Taxes
- Unpaid Tax Liens
- Open Judgements
- None
Take advantage of funding to pay them off
Income Taxes Owed
Payroll Taxes Owed
Tax Liens Owed
Judgments Owed
Average Monthly Revenue*
Start Date
MM
DD
YYYY

Best Estimation
Credit Score
Has the borrower ever declared bankruptcy?*
- Yes
- No
Not an immediate disqualifier
Bankruptcy Type
Bankruptcy Results
Discharge Date
Date Format: MM slash DD slash YYYY

Business Name*
Address
Street Address Address Line 2 City State ZIP Code
Contact Name
First Last
Are The Owner(s) US Citizens or Green Card holders?*
- Yes
- No
Email*
Phone
Best contact number
Website
Is This A Home Based Business?
- Yes
- No
Do You Own Or Lease The Business Location
- Own
- Lease
Is The Guarantor A Home Owner?
- Yes
- No
Industry or Profession
Number of Employees
Legal Structure
Consent*
I agree to the privacy policy.
I Agree: By checking this box, you authorize Blue Note Assets and its successors, assigns and agents, to place autodialed calls and texts for telemarketing purposes to the telephone numbers provided on this application. Email updates and new program materials may also be sent.

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