Form
SQ - Success Quotient
CMG Intake LBE2174
Privacy
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SQ - Success Quotient

Name:

Company Name:

Email:

Phone:

Address:

City:

State:

ZIPCODE:

Website

Entity Structure

Corporation

LLC

Partnership

DBA

Sole Proprietorship

State Business Formed In:

State(s) Business Operates In:

Do you have any partners:

YES

NO

If YES, how many:

If this is a start-up, are you currently employed by another company:

YES

NO

How many full-time employees do you have:

Tell us about your business. What is your vision? What is your five year plan?

Do you have a business plan prepared?

YES

NO

Who do you bank with?

Have you discussed your current situation with your banker?

YES

NO

If YES, what feedback did they give you?

If NO, why not?

How much money do you need?

What is the money going to be used for (be specific)?

Do you have a loan package prepared?

YES

NO

Business Revenue 2022

Business Revenue 2023

Business Revenue 2024 (EST)

Business Net Profits 2022

Business Net Profits 2023

Business Net Profits 2024 (EST)

Business Bank Account average monthly balance:

What existing Trade/Vendor credit lines does the business have?

Business Credit Card #1

LIMIT 1

BALANCE 1

Business Credit Card #2

LIMIT 2

BALANCE 2

Business Credit Card #3

LIMIT 3

BALANCE 3

Bank Line of Credit (Name of Bank)

TOTAL LINE

BANK LINE BALANCE

DUNS Number

Dun & Bradstreet Paydex Score

Experian Intelliscore

Personal Bank Account average monthly balance:

FICO Score

Less than 550

550-599

600-649

650-699

700-749

750+

PERSONAL CREDIT CARD #1

PC LIMIT 1

PC BALANCE1

PERSONAL CREDIT CARD #2

PC LIMIT 2

PC BALANCE2

PERSONAL CREDIT CARD #3

PC LIMIT 3

BALANCE

PERSONAL INCOME 2023

ESTIMATED PERSONAL INCOME 2024

Are you current on all mortgages, credit cards, installment loans, etc.?

YES

NO

Have you ever filed for bankruptcy?

YES

NO

If YES; When?

Have you ever had any foreclosures?

YES

NO

If YES, when?

Do you have any pending claims, tax liens, lawsuits or judgments filed against you (personal and business)? If YES, please explain:

Notes and any additional pertinent information:

Thank you for contacting us.
We will get back to you as soon as possible.

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