Form
SQ - Success Quotient
CMG Intake LBE2174
Privacy
Terms and Conditions
SQ - Success Quotient
SQ - Success Quotient
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 2021
Business Revenue 2022
Business Revenue 2023 (EST)
Business Net Profits 2021
Business Net Profits 2022
Business Net Profits 2023 (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 2022
ESTIMATED PERSONAL INCOME 2023
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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