New Client Inquiry – Southern Oregon – Region #4 CAT New Client Inquiry – Southern Oregon – Region #4 (Counties: Coos, Douglas, Curry, Josephine, Jackson) Name* First Last Company Name* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Please tell us a little about your business...Are you a start-up or an existing business?* Start-Up Existing Business How many years has this business operated? What industry/sector is the business part of?* What type of business is it?* Number of full-time employees?* Number of part-time employees?* How much capital are you looking for?* Reason for capital?* Start Grow Refinance Disaster Assistance How much cash do you have available to invest in this business?* Have you been denied access to capital by a lender?* Yes No What is your timeline for your capital needs?*Now1 month3 months6 months9 months12 monthsUsing a 5-star rating, how would you rate your credit score?* 1 star 2 stars 3 stars 4 stars 5 stars (1 = less than good) (5 = excellent)Please share your current level of readiness to seek financing and work with the Capital Access Team:I have an updated business plan.* Yes No Not Applicable I have 24 months of month-by-month financial projections.* Yes No Not Applicable I have 3 years of personal tax returns.* Yes No Not Applicable I have 3 years of business tax returns (for this existing business).* Yes No Not Applicable I have completed an updated Personal Financial Statement.* Yes No Not Applicable I have my credit report available to review.* Yes No Not Applicable Are you currently working with your local Small Business Development Center (SBDC) on getting funded?* Yes No How did you learn about the OSBDCN's Capital Access Team?* Referral from my SBDC advisor Referral from my banker Personal research Referral from economic development professional Referral from another client If you received a referral to the Capital Access Team, please share specifically who referred you and from where.Example: (Jeff Jacobs - SBDC Advisor - Lane Community College SBDC - Eugene)CommentsThis field is for validation purposes and should be left unchanged.