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Loan Application

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Referral Information

Please provide your information




Please ensure that no extra space is added before or after the valid email address.

Business Information

Please provide the Legal Name under which your business is registered.
If your Business operates under a name different than your Business Legal Name, then this field is required.








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Business Address

If your address includes an apartment number, please use the abbreviation "Apt" without additional punctuation or symbols. Example: Apt 123.



Business Address Zip Code





Personal Information





Please ensure that no extra space is added before or after the valid email address.



Home Address

If your address includes an apartment number, please use the abbreviation "Apt" without additional punctuation or symbols. Example: Apt 123.



Business Ownership


Other Owner Information





Home Address

If your address includes an apartment number, please use the abbreviation "Apt" without additional punctuation or symbols. Example: Apt 123.



Loan Information



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Use of Proceeds

Please provide an estimate of the use of proceeds for each category below.

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Collateral


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Please provide an estimate of each type of collateral available for this loan request.

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Business Interview













Optional Owner Demographics
Disclosure of this information is voluntary and has no bearing on the credit decision. This data is collected for program reporting purposes. The information provided will remain confidential and will be reported as borrower aggregate statistics, not individual data. This information helps Business Impact NW to improve its delivery of service and allows us to better fulfill our mission.


Please provide a short description








Financial Information
This section requires detailed financial information, and you may want to gather the following documentation before starting.

*Most recent tax return
*Current savings, checking, retirement, and other investment account statements
*Recent mortgage statements
*Documentation of the value of personal assets

Estimate of Assets


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Estimate of Liabilities



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Monthly Income and Expenses


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Terms and Conditions
The applicant certifies, under penalty of law, that all information provided in conjunction with this application is complete, true and correct to the best of their knowledge. The applicant authorizes Business Impact Northwest to make inquiries necessary to verify the accuracy of the statements made to determine creditworthiness.

Confidentiality Agreement

Business Impact Northwest agrees that it will use information obtained in this application only for the purpose of assessing the applicants credit worthiness. Business Impact Northwest will take all reasonable precautions to ensure that all information in this loan application remains confidential. 
Form ID 4961724 v0.12

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